Provider Demographics
NPI:1003880683
Name:REPPERT, MATTHEW KELSEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:KELSEY
Last Name:REPPERT
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 1:20 OVERBROOK RD
Mailing Address - Street 2:
Mailing Address - City:PAINTED POST
Mailing Address - State:NY
Mailing Address - Zip Code:14870-9339
Mailing Address - Country:US
Mailing Address - Phone:607-368-0334
Mailing Address - Fax:
Practice Address - Street 1:20 OVERBROOK RD
Practice Address - Street 2:
Practice Address - City:PAINTED POST
Practice Address - State:NY
Practice Address - Zip Code:14870-9339
Practice Address - Country:US
Practice Address - Phone:607-368-0334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044340E208600000X
NY192911-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01431621Medicaid
NYCC8362OtherRR MEDICARE GROUP
NY020049791OtherRR MEDICARE PIN
PA0014394690003Medicaid
F64037Medicare UPIN
NY39822PMedicare ID - Type Unspecified