Healthcare Provider Details

I. General information

NPI: 1760984421
Provider Name (Legal Business Name): STEPHEN AARON CUPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8402 BLACKJACK RD
MOUNT VERNON OH
43050-9193
US

IV. Provider business mailing address

13843 SIMMONS RD
UTICA OH
43080-9586
US

V. Phone/Fax

Practice location:
  • Phone: 740-522-8477
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: