Basic Information
| Provider Information | |||||||||
| NPI: | 1417966987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMONE | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735035 | ||||||||
| FaxNumber: | 2079735042 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 STATE ST | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079890550 | ||||||||
| FaxNumber: | 2079890551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 06/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1282 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 283360099 | 05 | ME | MEDICAID | M61761 | 01 | ME | CIGNA | OTHER | 001146 | 01 | ME | ANTHEM BC BS | OTHER | 1044459 | 01 | ME | AETNA | OTHER | 10474554 | 01 | ME | MEDNET | OTHER | E69439 | 01 | ME | HARVARD PILGRIM | OTHER |