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, DETROIT, MI 48201-2013
(313) 745-4525
(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
363L00000X
Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0H22830
BCBSM GROUP NUMBER
MI
01
—
0P32180
MEDICARE GROUP # - NP
MI
01
—
23D0650703
CLIA COMPLIANCE DERM
MI
01
—
23D0685178
CLIA COMPLIANCE DERM
MI
01
—
23D0701622
CLIA - PPM (MODERATE COMPLEXITY)
MI
01
—
23D1096986
CLIA MICROSCOPY
MI
01
—
23D2054540
CLIA REGISTRATION (HIGH COMPLEXITY)
MI
Enumeration date
06/06/2006
Last updated
10/26/2016
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