Provider Demographics
NPI:1770650970
Name:SIMMONS, AGNES H (M D)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:H
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 13042
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101
Mailing Address - Country:US
Mailing Address - Phone:215-747-1744
Mailing Address - Fax:215-747-0336
Practice Address - Street 1:6201 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-2906
Practice Address - Country:US
Practice Address - Phone:215-747-1744
Practice Address - Fax:215-747-0336
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021009E207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000632366Medicaid
PA025781Medicare ID - Type Unspecified
PA000632366Medicaid