Provider Demographics
NPI:1669727566
Name:THOMAS A UPSHAW, MD, PA
Entity type:Organization
Organization Name:THOMAS A UPSHAW, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:UPSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-754-4655
Mailing Address - Street 1:1336 NEWPORT CT
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8262
Mailing Address - Country:US
Mailing Address - Phone:843-754-4655
Mailing Address - Fax:
Practice Address - Street 1:728 S SHELMORE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-1601
Practice Address - Country:US
Practice Address - Phone:843-972-0262
Practice Address - Fax:843-972-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18101261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCF89888-0281Medicare UPIN