Healthcare Provider Details

I. General information

NPI: 1093823957
Provider Name (Legal Business Name): JANA UPSHAW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 HOUSTON NORTHCUTT BLVD STE E
MOUNT PLEASANT SC
29464-3487
US

IV. Provider business mailing address

2880 TRICOM ST
NORTH CHARLESTON SC
29406-9171
US

V. Phone/Fax

Practice location:
  • Phone: 843-471-0375
  • Fax: 843-806-4300
Mailing address:
  • Phone: 843-797-5050
  • Fax: 843-797-3633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2010-01542
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number18649
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number18649
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: