# 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:** 1346289147
- **Authorized official:** MR. JEFFERY P KOHLITZ (CHIEF FINANCIAL OFFICER)
- **Authorized official phone:** (248) 581-5930

## Contact information

- **Practice address:** 4100 JOHN R ST, DETROIT, MI 48201-2013
- **Practice address phone:** (313) 745-4525
- **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 |
| --- | --- | --- | --- | --- |
| 363L00000X | Nurse Practitioner | — | NULL | Yes |
| 363L00000X | Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 06/06/2006
- **Last updated:** 10/26/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0H22830 | BCBSM GROUP NUMBER | MI |
| 01 | — | 0P32180 | MEDICARE GROUP \# - NP | MI |
| 01 | — | 23D0650703 | CLIA COMPLIANCE DERM | MI |
| 01 | — | 23D0685178 | CLIA COMPLIANCE DERM | MI |
| 01 | — | 23D0701622 | CLIA - PPM (MODERATE COMPLEXITY) | MI |
| 01 | — | 23D1096986 | CLIA MICROSCOPY | MI |
| 01 | — | 23D2054540 | CLIA REGISTRATION (HIGH COMPLEXITY) | MI |