Basic Information
Provider Information | |||||||||
NPI: | 1447465661 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY PHYSICIAN GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WAYNE STATE UNIVERSITY PHYSICIAN GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 3901 CHRYSLER DR | ||||||||
Address2: | TOLAN PARK | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482012167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139933434 | ||||||||
FaxNumber: | 3139933421 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2007 | ||||||||
LastUpdateDate: | 10/26/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOHLITZ | ||||||||
AuthorizedOfficialFirstName: | JEFFERY | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2485815930 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 |   | 163W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |   | 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 | 0P32060 | 01 | MI | MEDICARE GROUP # - PSYCHOLOGIST/NEUROPSYCHOLOGIST | OTHER | 0H22872 | 01 | MI | BCBSM GROUP#-SOCIAL WORKER | OTHER | 0H22872 | 01 | MI | BCBSM GROUP # - SOCIAL WORKER | OTHER | 0P32180 | 01 | MI | MEDICARE GROUP # - NP | OTHER | 0P32050 | 01 | MI | MEDICARE GROUP # - SOCIAL WORKER | OTHER | 0H22874 | 01 | MI | BCBSM GROUP # - PSYCHOLOGIST/NEUROPSYCHOLOGIST | OTHER | 0H22830 | 01 | MI | BCBSM GROUP # - NP | OTHER | 0H22832 | 01 | MI | BCBSM GROUP # - MD/DO | OTHER | 0P30630 | 01 | MI | MEDICARE GROUP # - MD/DO | OTHER | 0P32120 | 01 | MI | MEDICARE GROUP # - MD/DO FEE LOCALITY 99 | OTHER |