Provider Demographics
NPI:1043266620
Name:SHOUP, BRENDA (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:SHOUP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 W 74TH ST STE 130
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2207
Mailing Address - Country:US
Mailing Address - Phone:913-632-9130
Mailing Address - Fax:913-632-9149
Practice Address - Street 1:9301 W 74TH ST STE 130
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2207
Practice Address - Country:US
Practice Address - Phone:913-632-9130
Practice Address - Fax:913-632-9149
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005007820207VX0201X
KS431352207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7727356OtherAETNA
2231144OtherUHC
77780OtherHEALTHCARE USA
MO200459402Medicaid
35478013OtherBCBS OF KC
P00274849OtherRAILROAD MEDICARE
MOH61382Medicare UPIN
MO200459402Medicaid
2231144OtherUHC
7727356OtherAETNA
L76E098Medicare PIN