Provider Demographics
NPI:1205823762
Name:SIMON, KERRY MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:MARK
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 MEMORIAL DR STE 1200
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5770
Practice Address - Fax:920-361-5779
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4310075257207Q00000X
WI33205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4180186Medicaid
MI080155623OtherRR MEDICARE
MI0805300321OtherBLUE CROSS BLUE SHIELD
E69795Medicare UPIN
MI0M98780Medicare ID - Type Unspecified