Provider Demographics
NPI:1104063817
Name:DOWNRIVER CLINIC PC
Entity type:Organization
Organization Name:DOWNRIVER CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MEDICAL DIRECTOR PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MOUNIR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-675-0705
Mailing Address - Street 1:8944 MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-2089
Mailing Address - Country:US
Mailing Address - Phone:734-675-0705
Mailing Address - Fax:734-675-0747
Practice Address - Street 1:8944 MACOMB ST
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-2089
Practice Address - Country:US
Practice Address - Phone:734-675-0705
Practice Address - Fax:734-675-0747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091157261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care