Provider Demographics
NPI:1003033705
Name:GLEN W SIMONS, M.D., P.S.C.
Entity Type:Organization
Organization Name:GLEN W SIMONS, M.D., P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-455-8346
Mailing Address - Street 1:125 E MAXWELL ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-2678
Mailing Address - Country:US
Mailing Address - Phone:859-455-8346
Mailing Address - Fax:
Practice Address - Street 1:125 E MAXWELL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-2678
Practice Address - Country:US
Practice Address - Phone:859-455-8346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36709208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65935538Medicaid
KY65935538Medicaid
1896201Medicare ID - Type Unspecified