Healthcare Provider Details

I. General information

NPI: 1376128892
Provider Name (Legal Business Name): UPSTATE PODIATRY GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W MAIN ST
LAURENS SC
29360-2608
US

IV. Provider business mailing address

801 SE MAIN ST
SIMPSONVILLE SC
29681-7150
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

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