Healthcare Provider Details

I. General information

NPI: 1740389766
Provider Name (Legal Business Name): UPPER VALLEY PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 LOONEY RD SUITE 101
PIQUA OH
45356-4199
US

IV. Provider business mailing address

PO BOX 479
TROY OH
45373-0479
US

V. Phone/Fax

Practice location:
  • Phone: 937-440-8687
  • Fax: 937-773-8058
Mailing address:
  • Phone: 937-440-8687
  • Fax: 937-773-8058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: PAMELA RADER
Title or Position: ADMINISTRATOR
Credential:
Phone: 937-440-7454