=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912237652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAPLEWOOD PODIATRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2009
-----------------------------------------------------
Last Update Date | 01/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2520 WHITE BEAR AVE N SUITE A
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-5136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-770-3891
-----------------------------------------------------
Fax | 651-748-3117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2520 WHITE BEAR AVE N SUITE A
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-5136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-770-3891
-----------------------------------------------------
Fax | 651-748-3117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. VINCENT SIMONE JR.
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 651-770-3891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------