=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639431513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER VALLEY PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2012
-----------------------------------------------------
Last Update Date | 03/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3130 N COUNTY ROAD 25A
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45373-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-440-4466
-----------------------------------------------------
Fax | 937-440-7177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3130 N COUNTY ROAD 25A
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45373-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-440-4466
-----------------------------------------------------
Fax | 937-440-7177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF MANAGED CARE
-----------------------------------------------------
Name | MARK W SHAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-499-8834
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------