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NPI Code Detail

MEDICARE: JUPITER MEDICAL I LLC

MEDICARE: JUPITER MEDICAL I LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine PhysicianUT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1104346543
Entity Type Code : Organization
Provider Name (Legal Business Name) : JUPITER MEDICAL I LLC
Provider Business Mailing Address
First Line : 21 WHITE HILL RD
Second Line :
City : COLD SPRING HARBOR
State : NY
Zip : 11724-1211
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1784 UINTA WAY UNIT E2
Second Line :
City : PARK CITY
State : UT
Zip : 84098-7685
Country : US
Telephone Number : 435-604-0160
Fax Number : 435-731-8328
Authorized Official
Title or Position : OWNER
Name : MR. BRYAN KNEPPER
Credential :
Telephone Number : 617-571-3680
Provider Enumeration Date : 06/27/2017
Last Update Date : 06/27/2017

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Directions to “JUPITER MEDICAL I LLC ” Practice Location

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