1043266620 NPI number — BRENDA SHOUP MD

Table of content: BRENDA SHOUP MD (NPI 1043266620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043266620 NPI number — BRENDA SHOUP MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOUP
Provider First Name:
BRENDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043266620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9301 W 74TH ST STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAWNEE MISSION
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66204-2207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-632-9130
Provider Business Mailing Address Fax Number:
913-632-9149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9301 W 74TH ST STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAWNEE MISSION
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66204-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-632-9130
Provider Business Practice Location Address Fax Number:
913-632-9149
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VX0201X , with the licence number:  2005007820 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0201X , with the licence number: 431352 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7727356 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2231144 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 77780 . This is a "HEALTHCARE USA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200459402 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35478013 . This is a "BCBS OF KC" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00274849 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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