Healthcare Provider Details

I. General information

NPI: 1053334557
Provider Name (Legal Business Name): JEREMY ROBERT STUCK MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 W 3RD AVE
WILLIAMSON WV
25661-3508
US

IV. Provider business mailing address

59 RUSS ST
UNIONTOWN PA
15401-8934
US

V. Phone/Fax

Practice location:
  • Phone: 304-235-4300
  • Fax: 304-235-0176
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015972
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002281
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: