MEDICARE: UPPER VALLEY PROFESSIONAL CORPORATION

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	208000000X	Pediatrics Physician		OH

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

General Provider Information

NPI Number	:	1720170038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPPER VALLEY PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 479
Second Line	:
City	:	TROY
State	:	OH
Zip	:	45373-0479
Country	:	US
Telephone Number	:	937-440-8687
Fax Number	:	937-773-8058

Provider Business Practice Location Address
First Line	:	450 N HYATT ST
Second Line	:	SUITE 306
City	:	TIPP CITY
State	:	OH
Zip	:	45371-1433
Country	:	US
Telephone Number	:	937-440-8687
Fax Number	:	937-773-8058

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	PAMELA RADER
Credential	:
Telephone Number	:	937-440-7454

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	08/20/2010

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Directions to “UPPER VALLEY PROFESSIONAL CORPORATION ” Practice Location

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