MEDICARE: UPSTATE SURGERY CENTER, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	ASF-050	SC

General Provider Information

NPI Number	:	1619998523
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPSTATE SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	9709 LAKESIDE BLVD STE 350
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77381-1216
Country	:	US
Telephone Number	:	713-489-2198
Fax Number	:	713-489-2978

Provider Business Practice Location Address
First Line	:	10 ENTERPRISE BLVD STE 109
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-3534
Country	:	US
Telephone Number	:	864-813-7226
Fax Number	:	864-556-7552

Authorized Official
Title or Position	:	CEO
Name	:	DEVIN LARSEN
Credential	:
Telephone Number	:	713-489-2198

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	01/21/2026

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