Provider Demographics
NPI:1578563508
Name:SIMON, ROBERT W (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:SIMON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 HIGHWAY 17 SOUTH
Mailing Address - Street 2:
Mailing Address - City:N MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-4343
Mailing Address - Country:US
Mailing Address - Phone:843-272-7979
Mailing Address - Fax:843-272-3534
Practice Address - Street 1:2421 HIGHWAY 17 SOUTH
Practice Address - Street 2:
Practice Address - City:N MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-4343
Practice Address - Country:US
Practice Address - Phone:843-272-7979
Practice Address - Fax:843-272-3534
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1897111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH164Medicaid
SC5464Medicare ID - Type Unspecified
SCGCH164Medicaid