Provider Demographics
NPI:1336492354
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 1:44000 W 12 MILE RD STE 205
Practice Address - Street 2:WSUPG PM&R OAKWOOD
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2647
Practice Address - Country:US
Practice Address - Phone:248-465-0100
Practice Address - Fax:248-465-0107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083153225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630OtherMEDICARE GROUP #
MI0H70318OtherBCBSM GROUP#
MI0P30630Medicare PIN