Healthcare Provider Details

I. General information

NPI: 1023557618
Provider Name (Legal Business Name): JEROME J UPCHURCH SA-C, CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15811 CHAGALL TER
NORTH POTOMAC MD
20878-3461
US

IV. Provider business mailing address

15811 CHAGALL TER
NORTH POTOMAC MD
20878-3461
US

V. Phone/Fax

Practice location:
  • Phone: 215-518-2138
  • Fax:
Mailing address:
  • Phone: 215-518-2138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0136001197
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: