Provider Demographics
NPI:1174505457
Name:UPCHURCH, BRENT H (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:H
Last Name:UPCHURCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7885
Mailing Address - Fax:508-947-6337
Practice Address - Street 1:31 ROCHE BROTHERS WAY
Practice Address - Street 2:TWP, SUITE 140
Practice Address - City:N EASTON
Practice Address - State:MA
Practice Address - Zip Code:02767
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-894-0332
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59406208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3092411Medicaid
F26451Medicare UPIN
J12339Medicare ID - Type Unspecified