1588696280 NPI number — MR. MARTIN BRUCE SIMMONS OD

Table of content: MR. MARTIN BRUCE SIMMONS OD (NPI 1588696280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588696280 NPI number — MR. MARTIN BRUCE SIMMONS OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMMONS
Provider First Name:
MARTIN
Provider Middle Name:
BRUCE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMMONS
Provider Other First Name:
MARTIN
Provider Other Middle Name:
BRUCE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
I
Provider Other Credential Text:
O.D
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1588696280
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 W 24TH ST STE 401
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16502-2667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-455-7591
Provider Business Mailing Address Fax Number:
814-454-1467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4021 FAR HILLS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETTERING
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45429-2413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-293-2149
Provider Business Practice Location Address Fax Number:
937-395-9633
Provider Enumeration Date:
07/06/2006

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: 152W00000X , with the licence number:  OEG000681 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OPT006726 , 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: 1863649 . This is a "KEYSTONE SR BLUE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1016403560001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1315299 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 180649 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1863649 . This is a "KEYSTONE HLTH PLAN CENTRA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 27541 . This is a "HLTH ASSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5106063 . This is a "AETNA PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 27541 . This is a "HLTH AMERICA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1863649 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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