Basic Information
| Provider Information | |||||||||
| NPI: | 1942262555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIMONIAN SPORTS MEDICINE CLINIC A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28921 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937298921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592285448 | ||||||||
| FaxNumber: | 5592243920 | ||||||||
| Practice Location | |||||||||
| Address1: | 729 NORTH MEDICAL CENTER DRIVE WEST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936116880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594397633 | ||||||||
| FaxNumber: | 5594397631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | SIMONIAN | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5592284204 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G83773 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.