Basic Information
| Provider Information | |||||||||
| NPI: | 1497884605 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PRIMARY CARE PRACTICES, INC. | ||||||||
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| OtherOrganizationName: | UH STATE ROAD FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 772040 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482772040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163836480 | ||||||||
| FaxNumber: | 2163836745 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 E WASHINGTON ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307218474 | ||||||||
| FaxNumber: | 2162018952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | JANNA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR MED STAFF SERVICES & CRED | ||||||||
| AuthorizedOfficialTelephone: | 2168442045 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.