1093823957 NPI number — JANA UPSHAW MD

Table of content: JANA UPSHAW MD (NPI 1093823957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093823957 NPI number — JANA UPSHAW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UPSHAW
Provider First Name:
JANA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093823957
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2880 TRICOM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29406-9171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-797-5050
Provider Business Mailing Address Fax Number:
843-797-3633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
966 HOUSTON NORTHCUTT BLVD STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-3487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-471-0375
Provider Business Practice Location Address Fax Number:
843-806-4300
Provider Enumeration Date:
08/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  2010-01542 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080S0010X , with the licence number: 18649 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS0010X , with the licence number: 18649 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 186499 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".