Basic Information
| Provider Information | |||||||||
| NPI: | 1356423016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | SOLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOLA | ||||||||
| OtherFirstName: | MA.THERESA | ||||||||
| OtherMiddleName: | R. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2520 VALLEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | POINT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046754340 | ||||||||
| FaxNumber: | 3046756911 | ||||||||
| Practice Location | |||||||||
| Address1: | 2520 VALLEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | POINT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046754500 | ||||||||
| FaxNumber: | 3046744019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22919 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35-086077 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2708976 | 05 | OH | MEDICAID | 3810009604 | 05 | WV | MEDICAID |