Provider Demographics
NPI:1518002948
Name:SIMON, ROBERT R (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
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 1:10864 M 43
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-9551
Mailing Address - Country:US
Mailing Address - Phone:269-589-5229
Mailing Address - Fax:269-375-7565
Practice Address - Street 1:5555 GULL RD
Practice Address - Street 2:SUITE 209
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-7640
Practice Address - Country:US
Practice Address - Phone:269-589-5229
Practice Address - Fax:269-375-7565
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-056652207P00000X
AL44281208D00000X
AK189273208D00000X
ARE-15241208D00000X
AR66947208D00000X
AZ66947208D00000X
CAG33486208D00000X
MI4301035155208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA91520Medicare UPIN