Basic Information
Provider Information | |||||||||
NPI: | 1467440107 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIMON | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | S. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2041 MESA VALLEY WAY | ||||||||
Address2: | SUITE 100 | ||||||||
City: | AUSTELL | ||||||||
State: | GA | ||||||||
PostalCode: | 301068157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709441100 | ||||||||
FaxNumber: | 7709446469 | ||||||||
Practice Location | |||||||||
Address1: | 2041 MESA VALLEY WAY | ||||||||
Address2: | SUITE 100 | ||||||||
City: | AUSTELL | ||||||||
State: | GA | ||||||||
PostalCode: | 301068157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709441100 | ||||||||
FaxNumber: | 7709446469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2005 | ||||||||
LastUpdateDate: | 02/05/2009 | ||||||||
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 | 207X00000X | 040235 | GA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 000666311H | 05 | GA |   | MEDICAID | 000666311I | 05 | GA |   | MEDICAID | 000666311C | 05 | GA |   | MEDICAID | 000666311G | 05 | GA |   | MEDICAID |