Basic Information
| Provider Information | |||||||||
| NPI: | 1346289600 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PHYSICIAN GROUP | ||||||||
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| OtherOrganizationName: | WAYNE STATE UNIVERSITY PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | SUITE 400-CREDENTIALING DEPT. | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815973 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 27177 LAHSER RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480348416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483574151 | ||||||||
| FaxNumber: | 2483570229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 10/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | KOHLITZ | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2485815930 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 0P46750 | 01 | MI | MEDICARE GROUP # - AUDIOLOGIST | OTHER | 0F33443 | 01 | MI | BCBSM GROUP NUMBER | OTHER | 23D1065430 | 01 | MI | CLIA WAIVER | OTHER | 23D1086626 | 01 | MI | CLIA WAIVER | OTHER | 23D1091632 | 01 | MI | CLIA WAIVER | OTHER |