Provider Demographics
NPI:1992059968
Name:SIMEON H. WALL, MD A PROFESSIONAL MEDICAL CORP
Entity type:Organization
Organization Name:SIMEON H. WALL, MD A PROFESSIONAL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMEON
Authorized Official - Middle Name:HENINGER
Authorized Official - Last Name:WALL
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:318-795-0801
Mailing Address - Street 1:8600 FERN AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5639
Mailing Address - Country:US
Mailing Address - Phone:318-795-0801
Mailing Address - Fax:318-795-9492
Practice Address - Street 1:8600 FERN AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5639
Practice Address - Country:US
Practice Address - Phone:318-795-0801
Practice Address - Fax:318-795-9492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02970R208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA115649Medicaid
LAB61438Medicare UPIN
LA115649Medicaid