Provider Demographics
NPI:1437354594
Name:GEOFFREY SIMON MD
Entity Type:Organization
Organization Name:GEOFFREY SIMON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-738-0647
Mailing Address - Street 1:1656 CHAMPLIN AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4830
Mailing Address - Country:US
Mailing Address - Phone:315-738-0647
Mailing Address - Fax:315-738-9719
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-738-0647
Practice Address - Fax:315-738-9719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105165208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00590047Medicaid
NY00590047Medicaid
NYAA0756Medicare ID - Type Unspecified