Basic Information
| Provider Information | |||||||||
| NPI: | 1467788703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6045 KENNEDY BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH BERGEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070473246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018614443 | ||||||||
| FaxNumber: | 2018610941 | ||||||||
| Practice Location | |||||||||
| Address1: | 6045 KENNEDY BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH BERGEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070473246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018614443 | ||||||||
| FaxNumber: | 2018610941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2009 | ||||||||
| LastUpdateDate: | 08/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MB08657400 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 255146-1 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.