NPIMap

Organization Active NPI

University Physician Group

Doing business as Wayne State University Physician Group

  • Optometrist
  • Detroit, MI
National Provider Identifier
1063452233
Registry record updated Oct 26, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
UNIVERSITY PHYSICIAN GROUP
Doing business as
Wayne State University Physician Group
Practice address
4717 Saint Antoine St
Detroit, MI 48201-1423
Phone
(313) 577-8900
Fax
(313) 577-0700
NPI assigned
Jun 7, 2006
Last updated
Oct 26, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 26, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jeffery P Kohlitz
Title
Chief Financial Officer
Phone
(248) 581-5930

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X NU Primary

Addresses

Primary practice location

4717 Saint Antoine St
Detroit, MI 48201-1423

Mailing address

1560 E. Maple Rd.
Suite 400-Credentialing Dept.
Troy, MI 48083-1138
Phone (248) 581-5973

Other identifiers 3

IdentifierTypeStateIssuer
0H22869OtherMIBCBSM GROUP NUMBER
23D1091632OtherMICLIA WAIVER
0P32140OtherMIMEDICARE GROUP # - OD

Other names 1

  • Wayne State University Physician Group Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060419000518 MI Part B Supplier - Clinic/Group Practice 8628087681 Receives reassigned benefits from 755 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Detroit, MI; Farmington Hills, MI; Flint, MI; Highland Park, MI; Livonia, MI; Roseville, MI; Southfield, MI; Southgate, MI…

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

20400 Livernois Ave
Detroit, MI 48221
Phone (313) 864-3766

Practitioners & affiliated clinicians

Practitioners 39

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 39

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149638400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1477440000000",
    "number": "1063452233",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1560 E. MAPLE RD.",
            "address_2": "SUITE 400-CREDENTIALING DEPT.",
            "city": "TROY",
            "state": "MI",
            "postal_code": "480831138",
            "telephone_number": "248-581-5973",
            "fax_number": "248-581-5640"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4717 SAINT ANTOINE ST",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482011423",
            "telephone_number": "313-577-8900",
            "fax_number": "313-577-0700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UNIVERSITY PHYSICIAN GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-07",
        "last_updated": "2016-10-26",
        "status": "A",
        "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",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSM GROUP NUMBER",
            "identifier": "0H22869",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA WAIVER",
            "identifier": "23D1091632",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP # - OD",
            "identifier": "0P32140",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wayne State University Physician Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Detroit, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.