Healthcare Provider Details

I. General information

NPI: 1639330640
Provider Name (Legal Business Name): SUSAN RACHEL HUPP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CLIFTON RD NE
ATLANTA GA
30322-7208
US

IV. Provider business mailing address

2835 BRANDYWINE RD STE 400
ATLANTA GA
30341-5540
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-2593
  • Fax: 770-488-9408
Mailing address:
  • Phone: 404-256-2593
  • Fax: 770-488-9408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35094839
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberQ5671
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: