Basic Information
| Provider Information | |||||||||
| NPI: | 1750348595 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPSTATE CAROLINA RADIOLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 745812 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303745812 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 E WOOD ST | ||||||||
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| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293033040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645606522 | ||||||||
| FaxNumber: | 8889728644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HASWELL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 8645606522 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8902719 | 05 | NC | MEDICAID | PA0114 | 05 | SC | MEDICAID |