Healthcare Provider Details

I. General information

NPI: 1407510522
Provider Name (Legal Business Name): MICHAEL DYLAN SIMKO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8312 GREELEY BLVD
SPRINGFIELD VA
22152-2904
US

IV. Provider business mailing address

8312 GREELEY BLVD
SPRINGFIELD VA
22152-2904
US

V. Phone/Fax

Practice location:
  • Phone: 571-512-1478
  • Fax:
Mailing address:
  • Phone: 571-512-1478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604516
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: