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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
16836 NEWBURGH RD, LIVONIA, MI 48154-1600
(734) 464-4220
(734) 464-5885
Mailing address
1560 E MAPLE RD, STE 400-CREDENTIALING DEPT., TROY, MI 48083-1138
(248) 581-5973
(248) 581-5640
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
103G00000X
Clinical Neuropsychologist
—
—
103T00000X
Psychologist
—
—
104100000X
Social Worker
—
—
106H00000X
Marriage & Family Therapist
—
—
2084P0800X
Psychiatry Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0H22830
BCBSM GROUP # - NP
MI
01
—
0H22832
BCBSM GROUP # - MD/DO
MI
01
—
0H22872
BCBSM GROUP # - SOCIAL WORKER
MI
01
—
0H22874
BCBSM GROUP # - PSYCHOLOGIST/NEUROPSYCHOLOGIST
MI
01
—
0P30630
MEDICARE GROUP # - MD/DO
MI
01
—
0P32050
MEDICARE GROUP # - SOCIAL WORKER
MI
01
—
0P32060
MEDICARE GROUP # - PSYCHOLOGIST/NEUROPSYCHOLOGIST
MI
01
—
0P32120
MEDICARE GROUP # - MD/DO FEE LOCALITY 99
MI
01
—
0P32180
MEDICARE GROUP # - NP
MI
Enumeration date
05/11/2007
Last updated
10/26/2016
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