Healthcare Provider Details

I. General information

NPI: 1134387251
Provider Name (Legal Business Name): GEORGE D SHOUP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 BLUEBIRD BLVD POST OFFICE BOX 1466
FORT VALLEY GA
31030-5083
US

IV. Provider business mailing address

503 BLUE BIRD BOULEVARD POST OFFICE BOX 1466
FORT VALLEY GA
31030
US

V. Phone/Fax

Practice location:
  • Phone: 478-825-8954
  • Fax:
Mailing address:
  • Phone: 478-825-8954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28214
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: