Basic Information
| Provider Information | |||||||||
| NPI: | 1003910670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENRICO-SIMON | ||||||||
| FirstName: | AGNES | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2420 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255501528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046756817 | ||||||||
| FaxNumber: | 3046755893 | ||||||||
| Practice Location | |||||||||
| Address1: | 2420 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255501528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046756817 | ||||||||
| FaxNumber: | 3046755893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 01/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20514 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001723700 | 01 | WV | BCBS | OTHER | 2362269 | 05 | OH | MEDICAID | 3002914000 | 05 | WV | MEDICAID | 7133291 | 01 | WV | AETNA | OTHER |