Basic Information
| Provider Information | |||||||||
| NPI: | 1790725265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | MD MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE ROAD | ||||||||
| Address2: | SUITE 400-CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815976 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 JOHN R HWCRC 4TH FL | ||||||||
| Address2: | KARMANOS CANCER CENTER | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005276266 | ||||||||
| FaxNumber: | 3135768767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301047715 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RX0202X | 4301047715 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3102855 | 05 | MI | MEDICAID |