Provider Demographics
NPI:1013963982
Name:UPSTATE LUNG AND CRITICAL CARE SPECIALISTS PC
Entity Type:Organization
Organization Name:UPSTATE LUNG AND CRITICAL CARE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LASHANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-573-6320
Mailing Address - Street 1:151 HAROLD FLEMING CT
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-4225
Mailing Address - Country:US
Mailing Address - Phone:864-573-6320
Mailing Address - Fax:864-573-6323
Practice Address - Street 1:151 HAROLD FLEMING CT
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4225
Practice Address - Country:US
Practice Address - Phone:864-208-0347
Practice Address - Fax:864-573-6323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890729MMedicaid
SCGP3212Medicaid
SCGP3212Medicaid
SCCB6976Medicare PIN
NC890729MMedicaid