Provider Demographics
NPI:1619380946
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:PROJECT LEAD, PHARMACY
Authorized Official - Prefix:MS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-581-5429
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:248-581-5429
Mailing Address - Fax:248-581-5644
Practice Address - Street 1:1560 E MAPLE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1138
Practice Address - Country:US
Practice Address - Phone:248-581-5429
Practice Address - Fax:248-581-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0000000000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty