1104346675 NPI number — MRS. EVE BEAUDRY SIMONEAU MD PHD

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 1104346675 NPI number — MRS. EVE BEAUDRY SIMONEAU MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAUDRY SIMONEAU
Provider First Name:
EVE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMONEAU
Provider Other First Name:
EVE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD PHD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1104346675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/01/2018
NPI Reactivation Date:
07/10/2018

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
622 WEST 168TH STREET
Provider Second Line Business Mailing Address:
PH14-105
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-305-7369
Provider Business Mailing Address Fax Number:
212-305-9139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
622 WEST 168TH STREET
Provider Second Line Business Practice Location Address:
PH14-105
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-305-7369
Provider Business Practice Location Address Fax Number:
212-305-9139
Provider Enumeration Date:
06/26/2017

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: 204F00000X , with the licence number:  295181 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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