# UNIVERSITY PHYSICIAN GROUP

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Wayne State University Physician Group
- **Organization subpart:** No

## Provider details

- **NPI number:** 1336417146
- **Authorized official:** MR. JEFFERY P KOHLITZ (CHIEF FINANCIAL OFFICER)
- **Authorized official phone:** (248) 581-5930

## Contact information

- **Practice address:** 4100 JOHN R ST, KARMANOS CANCER CENTER-WERTZ CLINIC, DETROIT, MI 48201-2013
- **Practice address phone:** (800) 527-6266
- **Practice address fax:** (313) 576-8381
- **Mailing address:** 1560 E. MAPLE RD., SUITE 400-CREDENTIALING DEPT, TROY, MI 48083-1138
- **Mailing address phone:** (248) 581-5973
- **Mailing address fax:** (248) 581-5640

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 235Z00000X | Speech-Language Pathologist | 4301038094 | MI | Yes |

## Other

- **Enumeration date:** 12/07/2011
- **Last updated:** 10/26/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0H27520 | BCBSM GROUP NUMBER | MI |
| 01 | — | 0P30630 | MEDICARE GROUP \# | MI |
| 01 | — | 23D1065430 | CLIA WAIVER | MI |