Basic Information
| Provider Information | |||||||||
| NPI: | 1265409890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STUPPY | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2817 SAINT JOHNS BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
| FaxNumber: | 4176252279 | ||||||||
| Practice Location | |||||||||
| Address1: | 2817 SAINT JOHNS BLVD | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177812727 | ||||||||
| FaxNumber: | 4176252279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 02/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 102912 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | 102912 | MO | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LP2900X | 102912 | MO | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208646123 | 05 | MO | MEDICAID | 100182790B | 05 | OK | MEDICAID | 100368050E | 05 | KS | MEDICAID |