Provider Demographics
NPI:1629242037
Name:SIMMONS, MICHAEL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:SIMMONS
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 1:225 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2228
Mailing Address - Country:US
Mailing Address - Phone:276-236-6906
Mailing Address - Fax:
Practice Address - Street 1:225 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2228
Practice Address - Country:US
Practice Address - Phone:762-366-9062
Practice Address - Fax:276-236-7179
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL.4246R390200000X
VA0101271193208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA996498837DMedicaid
GA996498837CMedicaid
GAP00610148OtherRR MEDICARE
SC0657PAMedicaid
GA996498837DMedicaid