Provider Demographics
NPI:1982819744
Name:UPPER VALLEY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:UPPER VALLEY PROFESSIONAL CORPORATION
Other - Org Name:STANFIELD FAMILY CARE
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:937-339-1518
Mailing Address - Fax:937-339-1538
Practice Address - Street 1:31 S STANFIELD RD
Practice Address - Street 2:SUITE 304
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2374
Practice Address - Country:US
Practice Address - Phone:937-339-1518
Practice Address - Fax:937-339-1538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2616404Medicaid
OH2616404Medicaid