1609824416 NPI number — TIMOTHY SIMON MD

Table of content: TIMOTHY SIMON MD (NPI 1609824416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609824416 NPI number — TIMOTHY SIMON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMON
Provider First Name:
TIMOTHY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1609824416
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 N DECATUR RD
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30033-5949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-277-4277
Provider Business Mailing Address Fax Number:
404-292-6305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 N DECATUR RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30033-5949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-277-4277
Provider Business Practice Location Address Fax Number:
404-292-6305
Provider Enumeration Date:
05/04/2006

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: 208C00000X , with the licence number:  040846 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1700465 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4608346001 . This is a "CIGNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00947086A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2969776 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7375431 . This is a "AETNA NON HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10556 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52439381 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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