1326000985 NPI number — MRS. ROSE A. SIMON LPN

Table of content: MRS. ROSE A. SIMON LPN (NPI 1326000985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326000985 NPI number — MRS. ROSE A. SIMON LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMON
Provider First Name:
ROSE
Provider Middle Name:
A.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BIRSCHBACH
Provider Other First Name:
ROSE
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326000985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3640 GREEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOCKE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13092-3273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-224-5001
Provider Business Mailing Address Fax Number:
315-224-5001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 CECIL MALONE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITHACA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14850-5124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-273-0466
Provider Business Practice Location Address Fax Number:
607-273-0466
Provider Enumeration Date:
04/06/2006

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: 164W00000X , with the licence number:  11271-031 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 164W00000X , with the licence number: 3063031 , 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)

  • Identifier: 161413735 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1841595 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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