Provider Demographics
NPI:1952397705
Name:SHANE M SOPP, MD PC
Entity Type:Organization
Organization Name:SHANE M SOPP, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-492-5005
Mailing Address - Street 1:PO BOX 2003
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4503
Mailing Address - Country:US
Mailing Address - Phone:315-446-3904
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:CGH POB SUITE 2V
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5005
Practice Address - Fax:315-492-5324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01992896Medicaid
NY01992896Medicaid
CJ2478Medicare PIN