Provider Demographics
NPI:1194310797
Name:SIMON, PHILIP (DPT)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8935 UMBRIA PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1107
Mailing Address - Country:US
Mailing Address - Phone:330-328-9142
Mailing Address - Fax:
Practice Address - Street 1:3390 ANNAPOLIS LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5378
Practice Address - Country:US
Practice Address - Phone:763-767-0854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT016727225100000X
MN12165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist