Provider Demographics
NPI:1881689438
Name:SIMMONS, RICHARD GLEN JR (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GLEN
Last Name:SIMMONS
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W LOSEY ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT AIR FORCE BASE
Mailing Address - State:IL
Mailing Address - Zip Code:62225-5250
Mailing Address - Country:US
Mailing Address - Phone:618-256-6280
Mailing Address - Fax:618-256-7318
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AIR FORCE BASE
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-6280
Practice Address - Fax:618-256-7318
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2013-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-009848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN