MEDICARE: AGNES A ENRICO-SIMON, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386846707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGNES A ENRICO-SIMON, PLLC

Provider Business Mailing Address
First Line	:	2415 JACKSON AVE
Second Line	:
City	:	PT PLEASANT
State	:	WV
Zip	:	25550-2042
Country	:	US
Telephone Number	:	304-675-6090
Fax Number	:	304-675-5893

Provider Business Practice Location Address
First Line	:	2415 JACKSON AVE
Second Line	:
City	:	PT PLEASANT
State	:	WV
Zip	:	25550-2042
Country	:	US
Telephone Number	:	304-675-6090
Fax Number	:	304-675-5893

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	AGNES A ENRICO-SIMON
Credential	:	MD
Telephone Number	:	304-675-6817

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	08/22/2020

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