MEDICARE: GEORGE D SHOUP MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	28214	GA

General Provider Information

NPI Number	:	1134387251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE D SHOUP MD

Provider Business Mailing Address
First Line	:	503 BLUE BIRD BOULEVARD
Second Line	:	POST OFFICE BOX 1466
City	:	FORT VALLEY
State	:	GA
Zip	:	31030
Country	:	US
Telephone Number	:	478-825-8954
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 BLUEBIRD BLVD
Second Line	:	POST OFFICE BOX 1466
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-5083
Country	:	US
Telephone Number	:	478-825-8954
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	05/27/2008

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