Basic Information
| Provider Information | |||||||||
| NPI: | 1114162831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOEPKER | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 30 | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135289311 | ||||||||
| FaxNumber: | 4136440274 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 QUARRY HILL ROAD | ||||||||
| Address2: | |||||||||
| City: | LEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132430536 | ||||||||
| FaxNumber: | 4132438040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2008 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 240167 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 277561 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110151527A | 05 | MA | MEDICAID |