Provider Demographics
NPI:1376503292
Name:SIMON, EDWIN K (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:K
Last Name:SIMON
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:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-0610
Mailing Address - Country:US
Mailing Address - Phone:847-473-4357
Mailing Address - Fax:847-578-8671
Practice Address - Street 1:830 W END CT
Practice Address - Street 2:SUITE 400
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1344
Practice Address - Country:US
Practice Address - Phone:847-249-6910
Practice Address - Fax:847-249-6950
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361098102084P0800X
IL36.109812084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109810Medicaid
ILI42175Medicare UPIN
ILK23839Medicare ID - Type Unspecified