Provider Demographics
NPI:1013057520
Name:UPSTATE HOMECARE MD, LLC
Entity type:Organization
Organization Name:UPSTATE HOMECARE MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-654-6150
Mailing Address - Street 1:212 HORSEHEAD POINT
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-8010
Mailing Address - Country:US
Mailing Address - Phone:864-654-6150
Mailing Address - Fax:
Practice Address - Street 1:212 HORSE HEAD POINT DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-8010
Practice Address - Country:US
Practice Address - Phone:864-654-6150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10288207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4621Medicaid
SCGP4621Medicaid
SC8676Medicare PIN