1104048925 NPI number — JONATHAN ALAN SIMONS PHD PC

Table of content: (NPI 1104048925)

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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