Provider Demographics
NPI:1346229044
Name:SU, SIMON YONGQUAN (MD)
Entity Type:Individual
Prefix:
First Name:SIMON YONGQUAN
Middle Name:
Last Name:SU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:YONGQUAN
Other - Middle Name:
Other - Last Name:SU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:109 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-2410
Mailing Address - Country:US
Mailing Address - Phone:215-923-2810
Mailing Address - Fax:215-923-2925
Practice Address - Street 1:109 N 9TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-2410
Practice Address - Country:US
Practice Address - Phone:215-923-2810
Practice Address - Fax:215-923-2925
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065401Y207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01733013Medicaid
PA022225Medicare ID - Type Unspecified
PA01733013Medicaid