Provider Demographics
NPI:1164681052
Name:KUPPUSAMY, PRIYA SHANMUGA (MD)
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:SHANMUGA
Last Name:KUPPUSAMY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 S PACA ST
Mailing Address - Street 2:EMERGENCY MEDICINE, 6TH FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 S PACA ST
Practice Address - Street 2:EMERGENCY MEDICINE, 6TH FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1642
Practice Address - Country:US
Practice Address - Phone:410-328-8025
Practice Address - Fax:410-328-8028
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD72084207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD244198YHWBMedicare PIN