Provider Demographics
NPI:1811089121
Name:UPPER VALLEY PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:UPPER VALLEY PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:937-440-8687
Mailing Address - Fax:937-773-8058
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:SUITE 103
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-8687
Practice Address - Fax:937-773-8058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2616404Medicaid
OH9272591Medicare PIN