1275572075 NPI number — UNIVERSITY PHYSICIAN GROUP

Table of content: (NPI 1275572075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275572075 NPI number — UNIVERSITY PHYSICIAN GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY PHYSICIAN GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WAYNE STATE UNIVERSITY PHYSICIAN GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275572075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1560 E. MAPLE RD.
Provider Second Line Business Mailing Address:
SUITE 400-CREDENTIALING DEPT.
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48083-1138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-581-5973
Provider Business Mailing Address Fax Number:
248-581-5640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 SAINT ANTOINE ST
Provider Second Line Business Practice Location Address:
SUITE 5G
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-745-4095
Provider Business Practice Location Address Fax Number:
313-577-8555
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOHLITZ
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
248-581-5930

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0P32160 . This is a "MEDICARE GROUP # - DDS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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