Basic Information
| Provider Information | |||||||||
| NPI: | 1255378394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMONS | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 501 BATH RD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190073101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157859200 | ||||||||
| FaxNumber: | 2157859039 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 BATH RD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190073101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157859200 | ||||||||
| FaxNumber: | 2157859039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 01/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD027447L | PA | Y | Other Service Providers | Specialist | 207X00000X | MD027447L | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | HIGHMARK BLUE SHIELD | 01 | PA | 15410 | OTHER | IBC | 01 | PW | 0021789000 | OTHER | 101040658 0001 | 05 | PA | MEDICAID | 30017309 | 01 | PA | KEYSTONE MERCY | OTHER |