Basic Information
| Provider Information | |||||||||
| NPI: | 1255451183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 DEFENSE HWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555277246 | ||||||||
| FaxNumber: | 8662295063 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 BESTGATE RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555277246 | ||||||||
| FaxNumber: | 8662295063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | DOO65044 | MD | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0014X | D0065044 | MD | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102609154-0001 | 05 | PA | MEDICAID |