Provider Demographics
NPI:1437136108
Name:UPSTATE SURGERY PA
Entity Type:Organization
Organization Name:UPSTATE SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:A
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-886-9250
Mailing Address - Street 1:PO BOX 834
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29679-0834
Mailing Address - Country:US
Mailing Address - Phone:864-886-9250
Mailing Address - Fax:864-886-9251
Practice Address - Street 1:16 ACCOUNTANTS CIR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-2670
Practice Address - Country:US
Practice Address - Phone:864-886-9250
Practice Address - Fax:864-886-9251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22507208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT67488Medicaid
SCG98432Medicare UPIN