Provider Demographics
NPI:1053334557
Name:STUCK, JEREMY ROBERT (MPT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:ROBERT
Last Name:STUCK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 RUSS ST
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-8934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3508
Practice Address - Country:US
Practice Address - Phone:304-235-4300
Practice Address - Fax:304-235-0176
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015972225100000X
WV002281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000550Medicaid
WV571136141003OtherBLUE CROSS/BLUE SHIELD
ST4175091Medicare ID - Type Unspecified