Provider Demographics
NPI:1053471599
Name:PEPPERCORN, JEFFREY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
Last Name:PEPPERCORN
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:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-6500
Mailing Address - Fax:617-724-1079
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:YAWKEY 9A
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-6500
Practice Address - Fax:617-724-1079
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205640207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901937Medicaid
MA110003017/AMedicaid
NC2045331Medicare PIN
NCH38625Medicare UPIN
MA110003017/AMedicaid