Organization
UNIVERSITY PHYSICIAN GROUP
Active
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, KRESGE EYE INSTITUTE, 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
332H00000X
Eyewear Supplier
Primary
4301054761
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0H22996
BCBSM GROUP #
MI
01
—
5717980001
NGS
MI
Enumeration date
06/06/2006
Last updated
12/01/2016
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