Basic Information
Provider Information | |||||||||
NPI: | 1689695256 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIMON | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | ERIC | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5788 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802175788 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7209798969 | ||||||||
FaxNumber: | 3032021281 | ||||||||
Practice Location | |||||||||
Address1: | 11600 W 2ND PL | ||||||||
Address2: | ST. ANTHONY HOSPITAL, EMERGENCY DEPT. | ||||||||
City: | LAKEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 802281527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7203214161 | ||||||||
FaxNumber: | 7203214165 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2006 | ||||||||
LastUpdateDate: | 08/01/2013 | ||||||||
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 | 207P00000X | 35183 | CO | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7717960 | 05 | SD |   | MEDICAID | S2077 | 05 | NM |   | MEDICAID | 01351832 | 05 | CO |   | MEDICAID | 8472334 | 05 | WA |   | MEDICAID | P00384488 | 01 | CO | RR MEDICARE | OTHER | 200384180A | 05 | KS |   | MEDICAID | 122709200 | 05 | WY |   | MEDICAID | Z3274 | 05 | UT |   | MEDICAID | 143705 | 05 | AZ |   | MEDICAID |