Basic Information
| Provider Information | |||||||||
| NPI: | 1699771766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUPPER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3006 N COUNTY ROAD 25A | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373353518 | ||||||||
| FaxNumber: | 9373326857 | ||||||||
| Practice Location | |||||||||
| Address1: | 3006 N COUNTY ROAD 25A | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373353518 | ||||||||
| FaxNumber: | 9373326857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 08/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35052300K | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 35052300K | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 0600102 | 05 | OH | MEDICAID |