Basic Information
Provider Information | |||||||||
NPI: | 1366490617 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIMON | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 750 OLD HICKORY BLVD STE 1-260 | ||||||||
Address2: |   | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370274528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153767500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 750 OLD HICKORY BLVD STE 1-260 | ||||||||
Address2: |   | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370274528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153767500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 04/30/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | M-10835 | ID | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | MD201699 | LA | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | 44627 | TN | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | ME85283 | FL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
ID | Type | State | Issuer | Description | 1514254 | 05 | TN |   | MEDICAID |