Provider Demographics
NPI:1598806960
Name:UPLAND ORTHOPAEDIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:UPLAND ORTHOPAEDIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-986-0494
Mailing Address - Street 1:1520 N MOUNTAIN AVE BLDG E
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-1128
Mailing Address - Country:US
Mailing Address - Phone:909-986-0494
Mailing Address - Fax:909-986-0497
Practice Address - Street 1:1520 N MOUNTAIN AVE BLDG E
Practice Address - Street 2:SUITE 205
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-1128
Practice Address - Country:US
Practice Address - Phone:909-986-0494
Practice Address - Fax:909-986-0497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty