Provider Demographics
NPI:1740590678
Name:UNIVERSITY PHYSICIAN GROUP
Entity Type:Organization
Organization Name:UNIVERSITY PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:K
Authorized Official - Last Name:STILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-581-5943
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 1:4700 SCHAEFER RD
Practice Address - Street 2:SUITE 165
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3698
Practice Address - Country:US
Practice Address - Phone:313-945-7724
Practice Address - Fax:313-945-8731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054761332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5717980004OtherNGS
MI5717980004Medicare NSC