1861016255 NPI number — PHILLIP E SIMS CDCA

Table of content: PHILLIP E SIMS CDCA (NPI 1861016255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861016255 NPI number — PHILLIP E SIMS CDCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMS
Provider First Name:
PHILLIP
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CDCA
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:
1861016255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRONTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45638-0108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-532-1613
Provider Business Mailing Address Fax Number:
740-532-1715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRONTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45638-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-532-1613
Provider Business Practice Location Address Fax Number:
740-532-1715
Provider Enumeration Date:
06/02/2020

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: 171M00000X , with the licence number:  CDCA.173793 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0405300 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".