Provider Demographics
NPI:1154360402
Name:UNIVERSITY PHYSICIAN GROUP
Entity type:Organization
Organization Name:UNIVERSITY PHYSICIAN GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:P
Authorized Official - Last Name:K
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-581-5930
Mailing Address - Street 1:1560 E. MAPLE RD.
Mailing Address - Street 2:SUITE 400-CREDENTIALING DEPT.
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:248-581-5973
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:16836 NEWBURGH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1600
Practice Address - Country:US
Practice Address - Phone:888-362-7792
Practice Address - Fax:734-464-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H22872OtherBCBSM GROUP NUMBER
MI0P32050OtherMEDICARE GROUP # - SOCIAL WORKER
MI0P32050OtherMEDICARE GROUP # - SOCIAL WORKER