Healthcare Provider Details

I. General information

NPI: 1265647481
Provider Name (Legal Business Name): UNIVERSITY PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST 4TH FLR CARLS BLDG
DETROIT MI
48201-2119
US

IV. Provider business mailing address

1560 E MAPLE RD STE 400-CREDENTIALING DEPT.
TROY MI
48083-1138
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4878
  • Fax: 313-993-0282
Mailing address:
  • Phone: 248-581-5973
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFERY P KOHLITZ
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 248-581-5930