Provider Demographics
NPI:1700056058
Name:IDELLA SIMMONS MD FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:IDELLA SIMMONS MD FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IDELLA
Authorized Official - Middle Name:N
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-916-9946
Mailing Address - Street 1:950 N ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3350
Mailing Address - Country:US
Mailing Address - Phone:317-916-9946
Mailing Address - Fax:317-916-9979
Practice Address - Street 1:950 N ALABAMA ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3350
Practice Address - Country:US
Practice Address - Phone:317-916-9946
Practice Address - Fax:317-916-9979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050509A173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1700056058Medicare UPIN
IN1912085879Medicare UPIN