Healthcare Provider Details

I. General information

NPI: 1790813590
Provider Name (Legal Business Name): SLEEP MEDICINE ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SPENCER ST
MANCHESTER CT
06040-4601
US

IV. Provider business mailing address

112 SPENCER ST
MANCHESTER CT
06040-4601
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. RICHARD MAHLON SHOUP
Title or Position: OWNER
Credential: M.D.
Phone: 860-432-5600