Provider Demographics
NPI:1558319764
Name:SIMONS, BEVERLY Y
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:Y
Last Name:SIMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2647
Mailing Address - Country:US
Mailing Address - Phone:803-758-2600
Mailing Address - Fax:
Practice Address - Street 1:110 ATRIUM WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6301
Practice Address - Country:US
Practice Address - Phone:803-788-1153
Practice Address - Fax:803-736-3243
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC132369Medicaid
F02155Medicare UPIN