Provider Demographics
NPI:1992742837
Name:SIMON, IFEKAN-SHANGO
Entity type:Individual
Prefix:
First Name:IFEKAN-SHANGO
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 N CHURCH ST
Mailing Address - Street 2:SUITE 510
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3077
Mailing Address - Country:US
Mailing Address - Phone:864-560-1558
Mailing Address - Fax:
Practice Address - Street 1:853 N CHURCH ST
Practice Address - Street 2:SUITE 510
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3098
Practice Address - Country:US
Practice Address - Phone:864-560-1558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC223528Medicaid
SCG98423Medicare PIN
SC223528Medicaid
SCSC12096067Medicare PIN
SCG984233365Medicare PIN
SC080171889Medicare PIN