Basic Information
Provider Information
NPI: 1952397705
EntityType: 2
ReplacementNPI:  
OrganizationName: SHANE M SOPP, MD PC
LastName:  
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MiddleName:  
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Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: PO BOX 2003
Address2:  
City: EAST SYRACUSE
State: NY
PostalCode: 130574503
CountryCode: US
TelephoneNumber: 3154463904
FaxNumber: 3154452936
Practice Location
Address1: 4900 BROAD RD
Address2: CGH POB SUITE 2V
City: SYRACUSE
State: NY
PostalCode: 132152265
CountryCode: US
TelephoneNumber: 3154925005
FaxNumber: 3154925324
Other Information
ProviderEnumerationDate: 09/26/2005
LastUpdateDate: 02/07/2008
NPIDeactivationReasonCode:  
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NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SOPP
AuthorizedOfficialFirstName: SHANE
AuthorizedOfficialMiddleName: M
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 3154925005
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207VG0400X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology

ID Information
IDTypeStateIssuerDescription
0199289605NY MEDICAID


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