Provider Demographics
NPI:1699908160
Name:THERESA SIMON MD, PLLC
Entity type:Organization
Organization Name:THERESA SIMON MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-675-4912
Mailing Address - Street 1:2924 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:PT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-1716
Mailing Address - Country:US
Mailing Address - Phone:304-675-4912
Mailing Address - Fax:304-675-4311
Practice Address - Street 1:2924 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:PT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-1716
Practice Address - Country:US
Practice Address - Phone:304-675-4912
Practice Address - Fax:304-675-4311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-31
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35-086077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV=========OtherCOMMERCIAL INSURANCES