1447299797 NPI number — UNIVERSITY PHYSICIAN GROUP

Table of content: (NPI 1447299797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447299797 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:
1447299797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 MACK AVE STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48201-2136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-448-9006
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 ST. ANTOINE ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-745-4525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JUZYCH
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO, WAYNE HEALTH
Authorized Official Telephone Number:
313-448-9006

Provider Taxonomy Codes

  • Taxonomy code: 204F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207SG0201X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 23D0685178 . This is a "CLIA COMPLIANCE DERM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D0913773 . This is a "CLIA - MICROSCOPY OBGYN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D1080033 . This is a "CLIA - MICROSCOPY FAM MED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D1086626 . This is a "CLIA - WAIVER OTO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D1091632 . This is a "CLIA WAIVER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D1096986 . This is a "CLIA MICROSCOPY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D0701622 . This is a "CLIA - PPM (MODERATE COMPLEXITY)" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D1040688 . This is a "CLIA - MICROSCOPY UROLOGY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D2054540 . This is a "CLIA REGISTRATION (HIGH COMPLEXITY)" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0P30630 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D1019738 . This is a "CLIA - MICROSCOPY INT MED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0P32120 . This is a "MEDICARE GROUP # - MD/DO FEE LOCALITY 99" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D0650703 . This is a "CLIA COMPLIANCE DERM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0H22832 . This is a "BCBSM GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D0701623 . This is a "CLIA - MICROSCOPY INT MED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D1065430 . This is a "CLIA - WAIVER OTO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 23D2028433 . This is a "CLIA - MICROSCOPY FAM MED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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