1104048925 NPI number — JONATHAN ALAN SIMONS PHD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104048925 NPI number — JONATHAN ALAN SIMONS PHD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JONATHAN ALAN SIMONS PHD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104048925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 859
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWLEYS ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29585-0859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-828-0502
Provider Business Mailing Address Fax Number:
843-828-4402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1506 AZALEA DR
Provider Second Line Business Practice Location Address:
STE 602
Provider Business Practice Location Address City Name:
SURFSIDE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29575-5232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-828-0502
Provider Business Practice Location Address Fax Number:
843-828-4402
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STELLING
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
CLAIRE
Authorized Official Title or Position:
VICE PRESIDENT-OFFICE MANAGER
Authorized Official Telephone Number:
843-828-0502

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  639 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PS0245 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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