Provider Demographics
NPI:1225023344
Name:SIMMONS, MICHAEL GRAYSON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GRAYSON
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 BYRON RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35769-4051
Mailing Address - Country:US
Mailing Address - Phone:256-259-8765
Mailing Address - Fax:256-716-8060
Practice Address - Street 1:750 BYRON RD
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35769-4051
Practice Address - Country:US
Practice Address - Phone:256-259-8765
Practice Address - Fax:256-716-8060
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17993208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00820619CMedicaid
AL106277Medicaid
AL106278Medicaid
FL256068200Medicaid
AL106277Medicaid
ALF98812Medicare UPIN
AL510I340016Medicare PIN