Provider Demographics
NPI:1265647481
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:STE 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 1:3901 BEAUBIEN ST
Practice Address - Street 2:4TH FLR CARLS BLDG
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-4878
Practice Address - Fax:313-993-0282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H22832OtherBCBSM GROUP # - MD/DO
MI0H22872OtherBCBSM GROUP # - SOCIAL WORKER
MI0H22874OtherBCBSM GROUP # - PSYCHOLOGIST/NEUROPSYCHOLOGIST
MI0P32180OtherMEDICARE GROUP # - NP
MI0P32060OtherMEDICARE GROUP # - PSYCHOLOGIST/NEUROPSYCHOLOGIST
MI0P30630OtherMEDICARE GROUP # - MD/DO
MI0P32050OtherMEDICARE GROUP # - SOCIAL WORKER
MI0H228310OtherBCBSM GROUP # - NP
MI0H22821OtherBCBSM GROUP #
MI0P32120OtherMEDICARE GROUP # - MD/DO FEE LOCALITY 99