Provider Demographics
NPI:1417386095
Name:SIMERVILLE, BRIAN L (MA, ATC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:SIMERVILLE
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 FAWNS WALK
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-5657
Mailing Address - Country:US
Mailing Address - Phone:410-212-8506
Mailing Address - Fax:
Practice Address - Street 1:GOSSETT FOOTBALL TEAM HOUSE
Practice Address - Street 2:UNIVERSITY OF MARYLAND
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20742-0001
Practice Address - Country:US
Practice Address - Phone:301-314-9901
Practice Address - Fax:877-863-2802
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00001502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer