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General NPI Number Information
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NPI Number | 1275572075
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Entity Type | Organization
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Legal Business Name | UNIVERSITY PHYSICIAN GROUP
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Dates
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Enumeration Date | 06/06/2006
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Last Update Date | 10/26/2016
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Provider Practice Location Address
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Address Line | 4201 SAINT ANTOINE ST SUITE 5G
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City | DETROIT
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State | MI
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Zip | 48201-2153
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Country | US
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Telephone | 313-745-4095
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Fax | 313-577-8555
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Provider Business Mailing Address
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Address Line | 1560 E. MAPLE RD. SUITE 400-CREDENTIALING DEPT.
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City | TROY
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State | MI
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Zip | 48083-1138
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Country | US
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Telephone | 248-581-5973
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Fax | 248-581-5640
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. JEFFERY P KOHLITZ
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Credential |
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Telephone | 248-581-5930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number |
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License Number State |
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