Healthcare Provider Details

I. General information

NPI: 1437259470
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

471 MARKER RD
VERSAILLES OH
45380-9324
US

IV. Provider business mailing address

PO BOX 479
TROY OH
45373-0479
US

V. Phone/Fax

Practice location:
  • Phone: 937-526-9834
  • Fax: 937-526-9446
Mailing address:
  • Phone: 937-526-9834
  • Fax: 937-526-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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