Provider Demographics
NPI:1639554819
Name:MARTHA SHUPING MD
Entity Type:Organization
Organization Name:MARTHA SHUPING MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-699-8042
Mailing Address - Street 1:PO BOX 25062
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-5062
Mailing Address - Country:US
Mailing Address - Phone:336-745-7344
Mailing Address - Fax:336-768-1857
Practice Address - Street 1:2839 MAPLEWOOD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4114
Practice Address - Country:US
Practice Address - Phone:336-745-7344
Practice Address - Fax:336-768-1857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32172261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902384Medicaid
NC5902384Medicaid
NC2170301AMedicare PIN