Provider Demographics
NPI:1245431477
Name:SIMON-GOLDMAN, PHYLLIS G (MD)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:G
Last Name:SIMON-GOLDMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 UNION AVE
Mailing Address - Street 2:FREED, KLEINBERG, NUSSBAUM & FEST, KRONBERG, M.D., LLP
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741
Mailing Address - Country:US
Mailing Address - Phone:631-588-4442
Mailing Address - Fax:631-471-3039
Practice Address - Street 1:270 UNION AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741
Practice Address - Country:US
Practice Address - Phone:631-331-6200
Practice Address - Fax:631-331-6282
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240746-12080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03080866Medicaid