Basic Information
| Provider Information | |||||||||
| NPI: | 1356556575 | ||||||||
| 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: | STE 400-CREDENTIALING DEPT. | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815973 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 16836 NEWBURGH RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344644220 | ||||||||
| FaxNumber: | 7344645885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| 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 | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 101Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 0P30630 | 01 | MI | MEDICARE GROUP # - MD/DO | OTHER | 0P32120 | 01 | MI | MEDICARE GROUP # - MD/DO FEE LOCALITY 99 | OTHER | 0H22830 | 01 | MI | BCBSM GROUP # - NP | OTHER | 0H22832 | 01 | MI | BCBSM GROUP # - MD/DO | OTHER | 0H22872 | 01 | MI | BCBSM GROUP # - SOCIAL WORKER | OTHER | 0P32060 | 01 | MI | MEDICARE GROUP # - PSYCHOLOGIST/NEUROPSYCHOLOGIST | OTHER | 0P32050 | 01 | MI | MEDICARE GROUP # - SOCIAL WORKER | OTHER | 0H22874 | 01 | MI | BCBSM GROUP # - PSYCHOLOGIST/NEUROPSYCHOLOGIST | OTHER | 0P32180 | 01 | MI | MEDICARE GROUP # - NP | OTHER |