Provider Demographics
NPI:1184838377
Name:UPLAND EDGE MEDICAL GROUP
Entity Type:Organization
Organization Name:UPLAND EDGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:GEMBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-943-7997
Mailing Address - Street 1:112 COLUMBIA POINT DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4390
Mailing Address - Country:US
Mailing Address - Phone:509-943-7997
Mailing Address - Fax:509-943-7955
Practice Address - Street 1:112 COLUMBIA POINT DR
Practice Address - Street 2:SUITE 103
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4390
Practice Address - Country:US
Practice Address - Phone:509-943-7997
Practice Address - Fax:509-943-7955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042734305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8808911Medicare PIN