=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295034551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TOMAS KUPRYS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2011
-----------------------------------------------------
Last Update Date | 10/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 771 OLD NORCROSS RD STE 105
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-4977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-509-4030
-----------------------------------------------------
Fax | 404-847-4488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1805 VERNON RD
-----------------------------------------------------
City | LAGRANGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30240-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-845-9824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 2453
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 1111
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 0000
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 79992
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------