Provider Demographics
NPI:1811486764
Name:UPSTATE AFFILIATE ORGANIZATION
Entity type:Organization
Organization Name:UPSTATE AFFILIATE ORGANIZATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP PAYOR STRATEGIES & ALIGNMENT
Authorized Official - Prefix:
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:H
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-522-2286
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6307
Mailing Address - Fax:
Practice Address - Street 1:109 PHYSICIANS DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650
Practice Address - Country:US
Practice Address - Phone:864-797-9170
Practice Address - Fax:864-797-9175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL-0934282N00000X
261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health