MEDICARE: STANLEY UPCHURCH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	J5656	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083603021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STANLEY UPCHURCH MD

Provider Business Mailing Address
First Line	:	700 E MARSHALL AVE
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-5580
Country	:	US
Telephone Number	:	903-315-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 E MARSHALL AVE
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-5580
Country	:	US
Telephone Number	:	903-315-2000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	03/30/2018

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Directions to “ STANLEY UPCHURCH MD” Practice Location

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