Healthcare Provider Details

I. General information

NPI: 1164420634
Provider Name (Legal Business Name): BRUCE J SIMON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N DEPARTMENT OF SURGERY/TRAUMA/CRITICAL CARE
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

10 NIBLICK RD
SHREWSBURY MA
01545-7724
US

V. Phone/Fax

Practice location:
  • Phone: 508-856-5288
  • Fax: 508-856-4224
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number76579
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: