Basic Information
| Provider Information | |||||||||
| NPI: | 1285745158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHUPUT | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2975 EXECUTIVE PKWY | ||||||||
| Address2: | 200 | ||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840439642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019901911 | ||||||||
| FaxNumber: | 8019901912 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 C ST | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841431005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939582 | ||||||||
| FaxNumber: | 8017335618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 82-169038-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MD27419 | OR | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 003075300 | 05 | ID | MEDICAID | P00611182 | 01 | OR | RR MEDICARE | OTHER | 53268 | 01 | UT | HEALTHY U | OTHER | QM0000075886 | 01 | UT | ALTIUS | OTHER | 107005104101 | 01 | UT | IHC | OTHER | 100501223 | 05 | NV | MEDICAID | PRA05848 | 01 | UT | MOLINA | OTHER | 006393 | 05 | OR | MEDICAID | 2090168 | 01 | UT | UNITED HEALTHCARE | OTHER | 8492795 | 05 | WA | MEDICAID | 108049100 | 05 | WY | MEDICAID | 37817 | 01 | UT | PEHP | OTHER | 820838 | 05 | AZ | MEDICAID | 870545614SH1 | 01 | UT | EDUCATORS MUTUAL | OTHER | 1502954 | 01 | UT | UMWA | OTHER | 36407 | 01 | UT | DESERET MUTUAL | OTHER | 8597445 | 01 | UT | WORKERS COMP | OTHER |