Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080N0001X | Neonatal-Perinatal Doctor | 034637 | GA |
NPI | 1053319228 |
---|---|
Provider Name | Dr. Kenneth G. Kupke |
First Address | Atlanta, GA 30328-5382 |
Second Address | Atlanta, GA 30328-5382 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2005 |
Last Update Date | 13/04/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00470434A | (05) | GA |
00470434D | (05) | GA |
00470434E | (05) | GA |