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Organization
UNIVERSITY PHYSICIAN GROUP
Active
Organization
UNIVERSITY PHYSICIAN GROUP
Active
Other names
Wayne State University Physician Group
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFFERY P KOHLITZ (CHIEF FINANCIAL OFFICER)
(248) 581-5930
Entity
Organization
Contact information
Practice address
27177 LAHSER RD, SUITE 203, SOUTHFIELD, MI 48034-8416
(248) 357-4151
(248) 357-0229
Mailing address
1560 E MAPLE RD, SUITE 400-CREDENTIALING DEPT., TROY, MI 48083
(248) 581-5973
(248) 581-5640
Taxonomy
Speciality
Code
Description
License number
State
231H00000X
Audiologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0F33443
BCBSM GROUP NUMBER
MI
01
—
0P46750
MEDICARE GROUP # - AUDIOLOGIST
MI
01
—
23D1065430
CLIA WAIVER
MI
01
—
23D1086626
CLIA WAIVER
MI
01
—
23D1091632
CLIA WAIVER
MI
Enumeration date
06/05/2006
Last updated
10/26/2016
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