Provider Demographics
NPI:1942205844
Name:RUPP, THERESA ANNE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANNE
Last Name:RUPP
Suffix:
Gender:F
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 75268
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5268
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-654-7752
Practice Address - Street 1:65 BRICKYARD ROAD
Practice Address - Street 2:
Practice Address - City:DILLWYN
Practice Address - State:VA
Practice Address - Zip Code:23936-0030
Practice Address - Country:US
Practice Address - Phone:434-983-2722
Practice Address - Fax:434-983-1383
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2013-09-11
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-07-20
Provider Licenses
StateLicense IDTaxonomies
VA0101045988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E83388Medicare UPIN
VA016893M54Medicare PIN
VAP00603338Medicare PIN