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
26400 W 12 MILE RD, SUITE 60, SOUTHFIELD, MI 48034-1774
(248) 594-6702
(248) 594-6738
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
332H00000X
Eyewear Supplier
Primary
4301054761
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5717980008
NGS
MI
Enumeration date
01/27/2016
Last updated
12/01/2016
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