Provider Demographics
NPI:1821158379
Name:UPSTATE MEDICAL REHABILITATION
Entity Type:Organization
Organization Name:UPSTATE MEDICAL REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-232-8417
Mailing Address - Street 1:1003 GROVE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4626
Mailing Address - Country:US
Mailing Address - Phone:864-232-8417
Mailing Address - Fax:864-232-1511
Practice Address - Street 1:1003 GROVE RD
Practice Address - Street 2:SUITE E
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4626
Practice Address - Country:US
Practice Address - Phone:864-232-8417
Practice Address - Fax:864-232-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1396799763OtherNPI
SC1699727008OtherNPI
SC1659325934OtherNPI
SCGP2707Medicaid
SC1013980168OtherNPI
SC1962466276OtherNPI
SCGP1248Medicaid
SC20810000XOtherTAXONOMY
SC5235Medicare PIN
SC1659325934OtherNPI