Provider Demographics
NPI:1518930957
Name:SHOUP, RICHARD M (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:SHOUP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4601
Mailing Address - Country:US
Mailing Address - Phone:860-432-5600
Mailing Address - Fax:860-432-5622
Practice Address - Street 1:112 SPENCER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4601
Practice Address - Country:US
Practice Address - Phone:860-432-5600
Practice Address - Fax:860-432-5622
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033290207RS0012X, 207RP1001X
CT33290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001332907Medicaid
CT110008065Medicare ID - Type Unspecified
F96948Medicare UPIN