Basic Information
| Provider Information | |||||||||
| NPI: | 1265636575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654492732 | ||||||||
| FaxNumber: | 7654491196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 S CREASY LN | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479057438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654477447 | ||||||||
| FaxNumber: | 7654471767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A99981 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 01067700A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A999810 | 05 | CA | MEDICAID | 200973600 | 05 | IN | MEDICAID |