Healthcare Provider Details

I. General information

NPI: 1659320505
Provider Name (Legal Business Name): HI SUP SIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 LEWIS LANE SUITE 201
HAVRE DE GRACE MD
21078-3753
US

IV. Provider business mailing address

251 LEWIS LANE SUITE 201
HAVRE DE GRACE MD
21078-3753
US

V. Phone/Fax

Practice location:
  • Phone: 410-939-4477
  • Fax: 410-939-1153
Mailing address:
  • Phone: 410-939-4477
  • Fax: 410-939-1153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberD0046412
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0046412
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: