Provider Demographics
NPI:1447222039
Name:RONALD W SIMONSEN MD PC
Entity type:Organization
Organization Name:RONALD W SIMONSEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SIMONSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-723-6858
Mailing Address - Street 1:341 BIRD AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365
Mailing Address - Country:US
Mailing Address - Phone:814-723-6858
Mailing Address - Fax:
Practice Address - Street 1:341 BIRD AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365
Practice Address - Country:US
Practice Address - Phone:814-723-6858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD008430E207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000623240Medicaid
017461Medicare ID - Type Unspecified
PA000623240Medicaid