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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
3901 CHRYSLER DR, TOLAN PARK, DETROIT, MI 48201-2167
(313) 993-3434
(313) 993-3421
Mailing address
1560 E MAPLE RD, SUITE 400-CREDENTIALING DEPT., TROY, MI 48083-1138
(248) 581-5973
(248) 581-5640
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
103T00000X
Psychologist
—
—
104100000X
Social Worker
—
—
2084P0800X
Psychiatry Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0H22830
BCBSM GROUP NUMBER
MI
01
—
0H22832
BCBSM GROUP NUMBER
MI
01
—
0H22872
BCBSM GROUP NUMBER
MI
01
—
0H22874
BCBSM GROUP NUMBER
MI
Enumeration date
05/11/2007
Last updated
10/26/2016
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