Provider Demographics
NPI:1598908741
Name:SIMON, SCOTT GARY (DC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:GARY
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 1:1900 W RYAN RD
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-8233
Mailing Address - Country:US
Mailing Address - Phone:414-719-0314
Mailing Address - Fax:
Practice Address - Street 1:S71W23325 NATIONAL AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:BIG BEND
Practice Address - State:WI
Practice Address - Zip Code:53103-9495
Practice Address - Country:US
Practice Address - Phone:262-662-9775
Practice Address - Fax:262-662-9773
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4495-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPENDINGMedicaid
WIPENDINGMedicare PIN