Basic Information
| Provider Information | |||||||||
| NPI: | 1639330640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUPP | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | RACHEL | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2835 BRANDYWINE RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303415540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042562593 | ||||||||
| FaxNumber: | 7704889408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303227208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042562593 | ||||||||
| FaxNumber: | 7704889408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35094839 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | Q5671 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003216382A | 05 | GA | MEDICAID |