Provider Demographics
NPI:1497753685
Name:RUPP, GARRY H (MD)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:H
Last Name:RUPP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 183027 DEPT LB-05
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43218-3027
Mailing Address - Country:US
Mailing Address - Phone:614-891-0550
Mailing Address - Fax:614-891-0429
Practice Address - Street 1:5877 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-2859
Practice Address - Country:US
Practice Address - Phone:614-891-0550
Practice Address - Fax:614-891-0429
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-1374207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0245587Medicaid
0400674Medicare PIN
C01136Medicare UPIN