Basic Information
| Provider Information | |||||||||
| NPI: | 1528007325 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PHYSICIAN GROUP | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| 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: | 480831138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815973 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 CHRYSLER SERVICE DR | ||||||||
| Address2: | TOLAN PARK | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883627792 | ||||||||
| FaxNumber: | 3139933421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 10/26/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOHLITZ | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2485815930 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |
No ID Information.