Provider Demographics
NPI:1720091143
Name:RUPP, MICHAEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
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 1:408 SE MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681
Mailing Address - Country:US
Mailing Address - Phone:864-228-8010
Mailing Address - Fax:864-228-3050
Practice Address - Street 1:408 SE MAIN STREET
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681
Practice Address - Country:US
Practice Address - Phone:864-228-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2981Medicaid
SCGP2981Medicaid