MEDICARE: DR. AGNES A ENRICO-SIMON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	20514	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	001723700	OTHER	WV	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	7133291	OTHER	WV	AETNA

General Provider Information

NPI Number	:	1003910670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AGNES A ENRICO-SIMON MD

Provider Business Mailing Address
First Line	:	2420 JEFFERSON AVE
Second Line	:
City	:	PT PLEASANT
State	:	WV
Zip	:	25550-1528
Country	:	US
Telephone Number	:	304-675-6817
Fax Number	:	304-675-5893

Provider Business Practice Location Address
First Line	:	2420 JEFFERSON AVE
Second Line	:
City	:	PT PLEASANT
State	:	WV
Zip	:	25550-1528
Country	:	US
Telephone Number	:	304-675-6817
Fax Number	:	304-675-5893

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	02/19/2024

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