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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
18100 OAKWOOD BLVD, SUITE 300, DEARBORN, MI 48124-4085
(313) 429-7977
(313) 429-7981
Mailing address
1560 E. MAPLE RD., SUITE 400-CREDENTIALING, TROY, MI 48083-1138
(248) 581-5973
(248) 581-5640
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
4301028224
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0H28367
BCBSM GROUP #
MI
01
—
0P30630
MEDICARE GROUP#
MI
Enumeration date
02/05/2013
Last updated
10/26/2016
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