Provider Demographics
NPI:1619165719
Name:EVANSTON INTERNAL MEDICINE ASSOC.
Entity Type:Organization
Organization Name:EVANSTON INTERNAL MEDICINE ASSOC.
Other - Org Name:EVANSTON INTERNAL MEDICINE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-789-0524
Mailing Address - Street 1:150 ARROWHEAD DR
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-9353
Mailing Address - Country:US
Mailing Address - Phone:307-789-0524
Mailing Address - Fax:307-789-6398
Practice Address - Street 1:150 ARROWHEAD DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9353
Practice Address - Country:US
Practice Address - Phone:307-789-0524
Practice Address - Fax:307-789-6398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3812A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW307866Medicare PIN