Provider Demographics
NPI:1063452233
Name:UNIVERSITY PHYSICIAN GROUP
Entity Type:Organization
Organization Name:UNIVERSITY PHYSICIAN GROUP
Other - Org Name:WAYNE STATE UNIVERSITY PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:P
Authorized Official - Last Name:KOHLITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-581-5930
Mailing Address - Street 1:1560 E. MAPLE RD.
Mailing Address - Street 2:SUITE 400-CREDENTIALING DEPT.
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:248-581-5973
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:4717 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1423
Practice Address - Country:US
Practice Address - Phone:313-577-8900
Practice Address - Fax:313-577-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P32140OtherMEDICARE GROUP # - OD
MI23D1091632OtherCLIA WAIVER
MI0H22869OtherBCBSM GROUP NUMBER
MI5717980001Medicare NSC
MI5717980008Medicare NSC
MI5717980005Medicare NSC
MI5717980003Medicare NSC
MI23D1091632OtherCLIA WAIVER
MI5717980005Medicare NSC