Healthcare Provider Details

I. General information

NPI: 1023076353
Provider Name (Legal Business Name): SIMON ST. JOHN PRENDIVILLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 RANDOLPH ROAD SUITE 208
CHARLOTTE NC
28207-1200
US

IV. Provider business mailing address

13808 PROFESSIONAL CENTER DR
HUNTERSVILLE NC
28078-7948
US

V. Phone/Fax

Practice location:
  • Phone: 704-377-4009
  • Fax:
Mailing address:
  • Phone: 704-377-4009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number200300278
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: