Basic Information
| Provider Information | |||||||||
| NPI: | 1174505457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UPCHURCH | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417885 | ||||||||
| FaxNumber: | 5089476337 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 ROCHE BROTHERS WAY | ||||||||
| Address2: | TWP, SUITE 140 | ||||||||
| City: | N EASTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5088940332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 10/18/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 59406 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3092411 | 05 | MA | MEDICAID |