Healthcare Provider Details

I. General information

NPI: 1619479342
Provider Name (Legal Business Name): UPSTATE PODIATRY GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 MEDICAL RIDGE RD
CLINTON SC
29325-4542
US

IV. Provider business mailing address

801 SE MAIN ST
SIMPSONVILLE SC
29681-7150
US

V. Phone/Fax

Practice location:
  • Phone: 864-833-9274
  • Fax:
Mailing address:
  • Phone: 864-399-9070
  • Fax: 864-399-9664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE THOMAS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 864-399-9070