1134492465 NPI number — UNIVERSITY PHYSICIAN GROUP

Table of content: (NPI 1134492465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134492465 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:
Provider Other Organization Name Type Code:
6
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:
1134492465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1560 E MAPLE RD
Provider Second Line Business Mailing Address:
SUITE 400-CREDENTIALING DEPT.
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48083-1138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-581-5973
Provider Business Mailing Address Fax Number:
248-581-5640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 SCHAEFER RD
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48126-3698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-945-8270
Provider Business Practice Location Address Fax Number:
313-945-8731
Provider Enumeration Date:
02/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KOHLITZ
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
248-581-5930

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  4301054761 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5717980005 . This is a "NGS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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