Healthcare Provider Details

I. General information

NPI: 1851342067
Provider Name (Legal Business Name): UPSTATE GASTROENTEROLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922A MCCONNELL SPRINGS RD
ANDERSON SC
29621-2642
US

IV. Provider business mailing address

1922A MCCONNELL SPRINGS RD
ANDERSON SC
29621-2642
US

V. Phone/Fax

Practice location:
  • Phone: 864-716-6050
  • Fax: 864-716-6055
Mailing address:
  • Phone: 864-716-6050
  • Fax: 864-716-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID T WORTHAM
Title or Position: MD
Credential:
Phone: 864-716-6050