Healthcare Provider Details

I. General information

NPI: 1518930957
Provider Name (Legal Business Name): RICHARD M SHOUP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SPENCER ST
MANCHESTER CT
06040-4601
US

IV. Provider business mailing address

71 HAYNES ST
MANCHESTER CT
06040-4188
US

V. Phone/Fax

Practice location:
  • Phone: 860-432-5600
  • Fax: 860-432-5622
Mailing address:
  • Phone: 860-646-1222
  • Fax: 860-432-5622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33290
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number033290
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number033290
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: