Basic Information
| Provider Information | |||||||||
| NPI: | 1073502589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | EDWINA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24651 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 7225 OLD OAK BLVD | ||||||||
| Address2: | SUITE B311 | ||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441303339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 08/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35056075 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | P00111439 | 01 | OH | RR MEDICARE | OTHER | 0703037 | 05 | OH | MEDICAID |