Provider Demographics
NPI:1407904162
Name:UPSTATE MOBILE MEDICINE
Entity Type:Organization
Organization Name:UPSTATE MOBILE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-494-0999
Mailing Address - Street 1:125 TIMBERLAKE CIR
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-9659
Mailing Address - Country:US
Mailing Address - Phone:864-494-0999
Mailing Address - Fax:868-752-0951
Practice Address - Street 1:125 TIMBERLAKE CIR
Practice Address - Street 2:
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-9659
Practice Address - Country:US
Practice Address - Phone:864-494-0999
Practice Address - Fax:868-752-0951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4214Medicaid