Healthcare Provider Details

I. General information

NPI: 1770949729
Provider Name (Legal Business Name): MRS. SAMANTHA SIMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 5TH AVE
NEW YORK NY
10029-3119
US

IV. Provider business mailing address

92 E 55TH ST
BROOKLYN NY
11203-2606
US

V. Phone/Fax

Practice location:
  • Phone: 212-426-3400
  • Fax: 212-410-7561
Mailing address:
  • Phone: 917-674-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number626457
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: