1740375948 NPI number — DR. SIMONE F M COLLYMORE PH.D.

Table of content: DR. SIMONE F M COLLYMORE PH.D. (NPI 1740375948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740375948 NPI number — DR. SIMONE F M COLLYMORE PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLYMORE
Provider First Name:
SIMONE
Provider Middle Name:
F M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

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:
1740375948
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 FAIR ST
Provider Second Line Business Mailing Address:
PO BOX 3065
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12402-3065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-338-4784
Provider Business Mailing Address Fax Number:
845-454-1441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 FAIR STREET
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-338-4784
Provider Business Practice Location Address Fax Number:
845-454-1441
Provider Enumeration Date:
10/04/2006

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: 103G00000X , with the licence number:  013677 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 013677 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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