Provider Demographics
NPI:1639466055
Name:WSU PHYSICIAN GROUP
Entity Type:Organization
Organization Name:WSU PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER HUMAN RESOURCES
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-577-8579
Mailing Address - Street 1:4201 ST. ANTOINE - UNIVERSITY HEALTH CENTER
Mailing Address - Street 2:POD- 4H
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-577-4984
Mailing Address - Fax:
Practice Address - Street 1:4201 ST. ANTOINE - UNIVERSITY HEALTH CENTER
Practice Address - Street 2:POD 5A
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-4008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704217349363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty