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
4717 SAINT ANTOINE ST, DETROIT, MI 48201-1423
(313) 577-8900
(313) 577-0700
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
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0H22869
BCBSM GROUP NUMBER
MI
01
—
0P32140
MEDICARE GROUP # - OD
MI
01
—
23D1091632
CLIA WAIVER
MI
Enumeration date
06/07/2006
Last updated
10/26/2016
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