Healthcare Provider Details

I. General information

NPI: 1578779195
Provider Name (Legal Business Name): TIM SIMONSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N ARTHUR ST
HUMANSVILLE MO
65674-8655
US

IV. Provider business mailing address

1192 W PHEASANT RUN ST
SPRINGFIELD MO
65810-2515
US

V. Phone/Fax

Practice location:
  • Phone: 417-754-2208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number004253
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: