1528176807 NPI number — SIMON P REDMON II FNP

Table of content: SIMON P REDMON II FNP (NPI 1528176807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528176807 NPI number — SIMON P REDMON II FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDMON
Provider First Name:
SIMON
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
FNP
Provider Gender Code:
M

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:
1528176807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 S 28TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401-7246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-722-4300
Provider Business Mailing Address Fax Number:
601-579-5240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 BOBBY BEASLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEMINARY
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39479-5501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-722-4300
Provider Business Practice Location Address Fax Number:
601-722-9751
Provider Enumeration Date:
08/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R784157 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00114375 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640507572PA . This is a "AMERICAN ADMIN GROUP" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 2007587 . This is a "UHC" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".