Provider Demographics
NPI:1366441339
Name:UPPSTROM, ERICA L (MD)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:L
Last Name:UPPSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 GRAHAM RD STE C-2310
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-8023
Mailing Address - Country:US
Mailing Address - Phone:314-953-6300
Mailing Address - Fax:
Practice Address - Street 1:1225 GRAHAM RD
Practice Address - Street 2:STE 2310C
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8012
Practice Address - Country:US
Practice Address - Phone:314-953-6300
Practice Address - Fax:314-953-6309
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085630207RC0000X
MOR4F97207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
036085630OtherIDPA
MO202913174Medicaid
P00307303OtherRR MCR
036085630OtherIDPA
MO202913174Medicaid
MO905484884Medicare PIN