Provider Demographics
NPI:1447299797
Name:UNIVERSITY PHYSICIAN GROUP
Entity type:Organization
Organization Name:UNIVERSITY PHYSICIAN GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO, WAYNE HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JUZYCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-448-9006
Mailing Address - Street 1:400 MACK AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2136
Mailing Address - Country:US
Mailing Address - Phone:313-448-9006
Mailing Address - Fax:
Practice Address - Street 1:4201 ST. ANTOINE ST.
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No204F00000XAllopathic & Osteopathic PhysiciansTransplant SurgeryGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D0685178OtherCLIA COMPLIANCE DERM
MI23D0913773OtherCLIA - MICROSCOPY OBGYN
MI23D1080033OtherCLIA - MICROSCOPY FAM MED
MI23D1086626OtherCLIA - WAIVER OTO
MI23D1091632OtherCLIA WAIVER
MI23D1096986OtherCLIA MICROSCOPY
MI23D0701622OtherCLIA - PPM (MODERATE COMPLEXITY)
MI23D1040688OtherCLIA - MICROSCOPY UROLOGY
MI23D2054540OtherCLIA REGISTRATION (HIGH COMPLEXITY)
MI0P30630OtherMEDICARE GROUP #
MI23D1019738OtherCLIA - MICROSCOPY INT MED
MI0P32120OtherMEDICARE GROUP # - MD/DO FEE LOCALITY 99
MI23D0650703OtherCLIA COMPLIANCE DERM
MI0H22832OtherBCBSM GROUP NUMBER
MI23D0701623OtherCLIA - MICROSCOPY INT MED
MI23D1065430OtherCLIA - WAIVER OTO
MI23D2028433OtherCLIA - MICROSCOPY FAM MED
MI0P30630OtherMEDICARE GROUP #
MI23D0650703OtherCLIA COMPLIANCE DERM
MI0P30630Medicare PIN
MI0H22832OtherBCBSM GROUP NUMBER
MI23D2054540OtherCLIA REGISTRATION (HIGH COMPLEXITY)
MI23D0685178OtherCLIA COMPLIANCE DERM
MI23D0701622OtherCLIA - PPM (MODERATE COMPLEXITY)
MI5717980002Medicare NSC