Provider Demographics
NPI:1316055916
Name:SIMMONS, BERNARD RUSSELL (MD)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:RUSSELL
Last Name:SIMMONS
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 1:2737 WARM SPRINGS RD STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5328
Mailing Address - Country:US
Mailing Address - Phone:706-324-0662
Mailing Address - Fax:706-324-7821
Practice Address - Street 1:2737 WARM SPRINGS RD STE A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5328
Practice Address - Country:US
Practice Address - Phone:706-324-0662
Practice Address - Fax:706-324-7821
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014564208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00219986DMedicaid
GAE58999Medicare UPIN
GA00219986DMedicaid