Provider Demographics
NPI:1821099219
Name:HOOGENDYK, SIMON (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:HOOGENDYK
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 1:401 W KILGORE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1100
Mailing Address - Country:US
Mailing Address - Phone:269-342-9550
Mailing Address - Fax:269-342-8313
Practice Address - Street 1:401 W KILGORE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1100
Practice Address - Country:US
Practice Address - Phone:269-342-9550
Practice Address - Fax:269-342-8313
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI112058467OtherRAILROAD MEDICARE PROVIDER TRANSACTION ACCESS NUMBER
MI1023841Medicaid
MI0392925Medicare ID - Type Unspecified
MI1023841Medicaid