Basic Information
| Provider Information | |||||||||
| NPI: | 1093891129 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPPER VALLEY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3130 N COUNTY ROAD 25A | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374407626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3130 N COUNTY ROAD 25A | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374407626 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KRAUS | ||||||||
| AuthorizedOfficialFirstName: | REGINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXEC. DIRECTOR OF BEHAVIORAL HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 9374407626 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E-0003168 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 11391005 | 01 | OH | CAQH PROVIDER # | OTHER |