MEDICARE: SIDNEY KAY SIMONIAN D.O.

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	207W00000X	Ophthalmology Physician	SS0007420	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5630300	OTHER	MI	BLUE CROSS BLUE SHIELD
2	180008618	OTHER	MI	MRRR
3	1856303004	OTHER	MI	BCN
4	382318591	OTHER	MI	COMMERCIAL
5	8631110001	OTHER	MI	MRPB
6	382318591	OTHER	MI	VISION SERVICE PLAN / VSP
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902849045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIDNEY KAY SIMONIAN D.O.

Provider Business Mailing Address
First Line	:	1421 E 12 MILE RD BLDG A
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-2653
Country	:	US
Telephone Number	:	248-547-6656
Fax Number	:	248-547-5407

Provider Business Practice Location Address
First Line	:	1421 E. 12 MILE
Second Line	:	BLDG. A
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-2653
Country	:	US
Telephone Number	:	248-547-6656
Fax Number	:	248-547-5407

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	06/03/2011

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