MEDICARE: UNIVERSITY PRIMARY CARE PRACTICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1497884605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY PRIMARY CARE PRACTICES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 772040
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48277-2040
Country	:	US
Telephone Number	:	216-383-6480
Fax Number	:	216-383-6745

Provider Business Practice Location Address
First Line	:	805 E WASHINGTON ST STE 100
Second Line	:
City	:	MEDINA
State	:	OH
Zip	:	44256-3331
Country	:	US
Telephone Number	:	330-721-8474
Fax Number	:	216-201-8952

Authorized Official
Title or Position	:	DIRECTOR MED STAFF SERVICES & CRED
Name	:	JANNA M KENNEDY
Credential	:
Telephone Number	:	216-844-2045

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	03/16/2021

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