Healthcare Provider Details

I. General information

NPI: 1841664398
Provider Name (Legal Business Name): HILTON KUPSHIK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 W PACES FERRY RD NW WEST PACES FERRY RD
ATLANTA GA
30327-2656
US

IV. Provider business mailing address

769 W PACES FERRY RD NW
ATLANTA GA
30327-2656
US

V. Phone/Fax

Practice location:
  • Phone: 404-668-8895
  • Fax:
Mailing address:
  • Phone: 404-668-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number18995
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number18995
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: