# 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:** 1346289600
- **Authorized official:** MR. JEFFERY P KOHLITZ (CHIEF FINANCIAL OFFICER)
- **Authorized official phone:** (248) 581-5930

## Contact information

- **Practice address:** 27177 LAHSER RD, SUITE 203, SOUTHFIELD, MI 48034-8416
- **Practice address phone:** (248) 357-4151
- **Practice address fax:** (248) 357-0229
- **Mailing address:** 1560 E MAPLE RD, SUITE 400-CREDENTIALING DEPT., TROY, MI 48083
- **Mailing address phone:** (248) 581-5973
- **Mailing address fax:** (248) 581-5640

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 231H00000X | Audiologist | — | — | Yes |

## Other

- **Enumeration date:** 06/05/2006
- **Last updated:** 10/26/2016

## 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 |