Provider Demographics
NPI:1114384757
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
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 1:26400 W 12 MILE RD
Practice Address - Street 2:SUITE 60
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1774
Practice Address - Country:US
Practice Address - Phone:248-594-6702
Practice Address - Fax:248-594-6738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054761332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5717980008OtherNGS
MI5717980008OtherNGS