Provider Demographics
NPI:1386846707
Name:AGNES A ENRICO-SIMON, PLLC
Entity Type:Organization
Organization Name:AGNES A ENRICO-SIMON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:A
Authorized Official - Last Name:ENRICO-SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-675-6817
Mailing Address - Street 1:2415 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:PT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-2042
Mailing Address - Country:US
Mailing Address - Phone:304-675-6090
Mailing Address - Fax:304-675-5893
Practice Address - Street 1:2415 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:PT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-2042
Practice Address - Country:US
Practice Address - Phone:304-675-6090
Practice Address - Fax:304-675-5893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3002914000Medicaid