1770606147 NPI number — MS. SHOSHANA SUSAN SIMON MSN, RN, CS

Table of content: MRS. RACHEL R FAHNESTOCK (NPI 1871777540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770606147 NPI number — MS. SHOSHANA SUSAN SIMON MSN, RN, CS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMON
Provider First Name:
SHOSHANA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, CS
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:
1770606147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 LOGGER COURT
Provider Second Line Business Mailing Address:
SUITE 100G
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27609-8512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-855-9090
Provider Business Mailing Address Fax Number:
919-786-9154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 LOGGER CT
Provider Second Line Business Practice Location Address:
SUITE 100G
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609-8525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-855-9090
Provider Business Practice Location Address Fax Number:
919-786-9154
Provider Enumeration Date:
04/09/2007

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: 364SP0808X , with the licence number:  099925 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 76654 . This is a "BLUECROSS BLUE SHIELD ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: RA792 . This is a "EMPIRE BLUE CROSS BLUE SH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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