Provider Demographics
NPI:1639431513
Name:UPPER VALLEY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:UPPER VALLEY PROFESSIONAL CORPORATION
Other - Org Name:UPPER VALLEY HOSPITALIST GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-499-8834
Mailing Address - Street 1:3130 N COUNTY ROAD 25A
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1337
Mailing Address - Country:US
Mailing Address - Phone:937-440-4466
Mailing Address - Fax:937-440-7177
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-4466
Practice Address - Fax:937-440-7177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2616404Medicaid
OH9272591Medicare PIN