Provider Demographics
NPI:1104931211
Name:GLADWIN FAMILY CARE CENTER P C
Entity type:Organization
Organization Name:GLADWIN FAMILY CARE CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HICHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURBAJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-426-9399
Mailing Address - Street 1:3061 CHRISTY WAY
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2267
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:989-791-1392
Practice Address - Street 1:2137 W M61
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624
Practice Address - Country:US
Practice Address - Phone:989-426-9399
Practice Address - Fax:989-246-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4276035Medicaid
MI5203202Medicaid
MI5214752Medicaid
MI4989200Medicaid
MI4920566Medicaid
MI7116734Medicaid
MI7116734Medicaid
MIH22298Medicare UPIN
MI4276035Medicaid
MIP41150Medicare UPIN
MI4920566Medicaid
MIE00476Medicare UPIN
MI4989200Medicaid
MII60516Medicare UPIN
MIH75707Medicare UPIN