Provider Demographics
NPI:1447355086
Name:RUPP, CORLISS A (MD)
Entity type:Individual
Prefix:
First Name:CORLISS
Middle Name:A
Last Name:RUPP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2055C SCENIC HWY N # 187
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6105
Mailing Address - Country:US
Mailing Address - Phone:770-982-2525
Mailing Address - Fax:770-982-2526
Practice Address - Street 1:1711 ATHENS HWY STE 500
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-4210
Practice Address - Country:US
Practice Address - Phone:770-982-2525
Practice Address - Fax:770-982-2526
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0490912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
U1537Medicare ID - Type Unspecified
G07481Medicare UPIN