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General NPI Number Information
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NPI Number | 1457390254
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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 | 12/12/2007
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Provider Practice Location Address
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Address Line | 4201 SAINT ANTOINE ST. SUITE 8D
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City | DETROIT
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State | MI
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Zip | 48201
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Country | US
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Telephone | 313-745-4275
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Fax |
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Provider Business Mailing Address
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Address Line | 3800 WOODWARD AVE SUITE 600
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City | DETROIT
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State | MI
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Zip | 48201-2061
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIEF ADMINISTRATIVE OFFICER
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Name | MR. KENNETH P. LEE
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Credential |
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Telephone | 313-577-8112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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