Provider Demographics
NPI:1619479342
Name:UPSTATE PODIATRY GROUP, PA
Entity Type:Organization
Organization Name:UPSTATE PODIATRY GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-399-9070
Mailing Address - Street 1:801 SE MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-7150
Mailing Address - Country:US
Mailing Address - Phone:864-399-9070
Mailing Address - Fax:864-399-9664
Practice Address - Street 1:1012 MEDICAL RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-4542
Practice Address - Country:US
Practice Address - Phone:864-833-9274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UPSTATE PODIATRY GROUP, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric