Healthcare Provider Details

I. General information

NPI: 1649227331
Provider Name (Legal Business Name): ELLEN M SIMON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MEDICAL CENTER DR SUITE 3100
BRUNSWICK ME
04011-2653
US

IV. Provider business mailing address

121 MEDICAL CENTER DR SUITE 3100
BRUNSWICK ME
04011-2653
US

V. Phone/Fax

Practice location:
  • Phone: 207-729-7939
  • Fax: 207-725-4717
Mailing address:
  • Phone: 207-729-7939
  • Fax: 207-725-4717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number160838
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number160838
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD16225
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: