Basic Information
| Provider Information | |||||||||
| NPI: | 1326769399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | SAM | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 MONUMENT ROAD | ||||||||
| Address2: | OUTPATIENT BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191311689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158772000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4200 MONUMENT ROAD | ||||||||
| Address2: | OUTPATIENT BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191311689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158772000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2022 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | RN675125 | PA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.