=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942307285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMMONS MEDICAL CLINIC, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 12/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1026 N HIGHWAY 69
-----------------------------------------------------
City | FRONTENAC
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66763-8100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-231-9669
-----------------------------------------------------
Fax | 620-231-4585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 999
-----------------------------------------------------
City | FRONTENAC
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66763-0999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-231-9669
-----------------------------------------------------
Fax | 620-231-4585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. MICHAEL R SIMMONS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 620-231-9669
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 04-24193
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------