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 111, SOUTHFIELD, MI 48034-1771
(248) 357-4151
(248) 357-0229
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
332S00000X
Hearing Aid Equipment
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
23D1091632
CLIA WAIVER
MI
Enumeration date
06/05/2006
Last updated
12/27/2016
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