Healthcare Provider Details

I. General information

NPI: 1366651150
Provider Name (Legal Business Name): MICHAEL D SIMISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 WILSON AVE SW
CEDAR RAPIDS IA
52404-6340
US

IV. Provider business mailing address

4005 WILSON AVE SW
CEDAR RAPIDS IA
52404-6340
US

V. Phone/Fax

Practice location:
  • Phone: 319-826-3994
  • Fax: 319-826-3996
Mailing address:
  • Phone: 319-826-3994
  • Fax: 319-826-3996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number37768
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37768
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number37768
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier074570002
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: