Provider Demographics
NPI:1700893567
Name:RUPP, SUSAN E (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
Last Name:RUPP
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 W. MILL STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925
Mailing Address - Country:US
Mailing Address - Phone:920-623-1106
Mailing Address - Fax:920-623-1107
Practice Address - Street 1:146 W MILL ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1585
Practice Address - Country:US
Practice Address - Phone:920-623-1106
Practice Address - Fax:920-623-1107
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3512-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39000400Medicaid
WI39000400Medicaid
WI000035648Medicare ID - Type Unspecified