Healthcare Provider Details

I. General information

NPI: 1326397993
Provider Name (Legal Business Name): BRENT SIMON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W 3RD ST
PINCONNING MI
48650-9622
US

IV. Provider business mailing address

1003 WOODSIDE AVE
ESSEXVILLE MI
48732-1234
US

V. Phone/Fax

Practice location:
  • Phone: 989-879-3771
  • Fax: 989-879-3788
Mailing address:
  • Phone: 989-892-7722
  • Fax: 989-892-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006442
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: