Provider Demographics
NPI:1386677862
Name:UPSTATE MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:UPSTATE MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:LAGENE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-429-4507
Mailing Address - Street 1:408 N DUNCAN BYPASS
Mailing Address - Street 2:SUITE 11 BOX 3
Mailing Address - City:UNION
Mailing Address - State:SC
Mailing Address - Zip Code:29379
Mailing Address - Country:US
Mailing Address - Phone:864-429-4507
Mailing Address - Fax:864-429-4597
Practice Address - Street 1:408 N DUNCAN BYPASS
Practice Address - Street 2:SUITE 11 BOX 3
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379
Practice Address - Country:US
Practice Address - Phone:864-429-4507
Practice Address - Fax:864-429-4597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2751Medicaid
SC5694960001Medicare ID - Type Unspecified