Provider Demographics
NPI:1740389766
Name:UPPER VALLEY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:UPPER VALLEY PROFESSIONAL CORPORATION
Other - Org Name:PEDIATRIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:RADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-440-7454
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-0479
Mailing Address - Country:US
Mailing Address - Phone:937-440-8687
Mailing Address - Fax:937-773-8058
Practice Address - Street 1:280 LOONEY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-4199
Practice Address - Country:US
Practice Address - Phone:937-440-8687
Practice Address - Fax:937-773-8058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2616404Medicaid
OH2616404Medicaid