=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932148160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN H SHUPERT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2006
-----------------------------------------------------
Last Update Date | 05/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 N CROSS ST
-----------------------------------------------------
City | WEST UNION
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45693-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-544-8989
-----------------------------------------------------
Fax | 937-544-5659
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1735 27TH ST WALLER BUILDING, SUITE B06
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45662-2677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-356-8008
-----------------------------------------------------
Fax | 740-353-7900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35-083116
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------