Provider Demographics
NPI:1669511853
Name:SIMMERMAN, GREGORY ALAN (CCC AUDIOLOGIST)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALAN
Last Name:SIMMERMAN
Suffix:
Gender:M
Credentials:CCC AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 FLEDDERJOHN ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314
Mailing Address - Country:US
Mailing Address - Phone:304-344-4400
Mailing Address - Fax:304-344-4641
Practice Address - Street 1:1105 FLEDDERJOHN ROAD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314
Practice Address - Country:US
Practice Address - Phone:304-344-4400
Practice Address - Fax:304-344-4641
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA0062231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9704045000Medicaid
SI9328751Medicare ID - Type Unspecified
WV9704045000Medicaid