MEDICARE: MRS. MARLA MARIE SIMON CRNA

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	367500000X	Certified Registered Nurse Anesthetist	RN130747	OH

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	000000286052	OTHER	OH	ANTHEM #

General Provider Information

NPI Number	:	1043278435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARLA MARIE SIMON CRNA

Provider Business Mailing Address
First Line	:	7685 W PIQUA CLAYTON RD
Second Line	:
City	:	COVINGTON
State	:	OH
Zip	:	45318-8802
Country	:	US
Telephone Number	:	937-473-2919
Fax Number	:	937-473-2124

Provider Business Practice Location Address
First Line	:	7685 W PIQUA CLAYTON RD
Second Line	:
City	:	COVINGTON
State	:	OH
Zip	:	45318-8802
Country	:	US
Telephone Number	:	937-473-2919
Fax Number	:	937-473-2124

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	07/09/2007

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