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
4100 JOHN R ST, KARMANOS CANCER CENTER-WERTZ CLINIC, DETROIT, MI 48201-2013
(800) 527-6266
(313) 576-8381
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
235Z00000X
Speech-Language Pathologist
Primary
4301038094
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0H27520
BCBSM GROUP NUMBER
MI
01
—
0P30630
MEDICARE GROUP #
MI
01
—
23D1065430
CLIA WAIVER
MI
Enumeration date
12/07/2011
Last updated
10/26/2016
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