Basic Information
| Provider Information | |||||||||
| NPI: | 1497953467 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUPKA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 CANTON RD NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300608949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787415000 | ||||||||
| FaxNumber: | 6788194280 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 BILL CARRUTH PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | HIRAM | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787415000 | ||||||||
| FaxNumber: | 7704459013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 060588 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 483829670C | 05 | GA | MEDICAID |