Basic Information
| Provider Information | |||||||||
| NPI: | 1053380774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN-SIMMERMAN | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W WHITE RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473034988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776685621 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 253 SAGAMORE PKWY W | ||||||||
| Address2: | |||||||||
| City: | WEST LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479061501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | 7654488335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01029841A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100088630 | 05 | IN | MEDICAID | 9274775 | 01 | IN | PHCS PID NUMBER | OTHER | 000000183094 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 10825553 | 01 | IN | CAQH NUMBER | OTHER | MA15766030 | 05 | IN | MEDICAID |