Provider Demographics
NPI:1245247436
Name:SHUPECK, MALCOLM (MD)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:SHUPECK
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 1:5400 KENNEDY AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45213-2664
Mailing Address - Country:US
Mailing Address - Phone:513-281-3400
Mailing Address - Fax:513-527-2275
Practice Address - Street 1:5400 KENNEDY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45213-2664
Practice Address - Country:US
Practice Address - Phone:513-281-3400
Practice Address - Fax:513-527-2275
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00-38557207T00000X
OH35-0917812085R0202X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2966474Medicaid
NC8976094Medicaid
OH2966474Medicaid
NC8976094Medicaid
OHSH4256502Medicare PIN