Provider Demographics
NPI:1942262555
Name:SIMONIAN SPORTS MEDICINE CLINIC A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SIMONIAN SPORTS MEDICINE CLINIC A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:T
Authorized Official - Last Name:SIMONIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-228-4204
Mailing Address - Street 1:PO BOX 28921
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8921
Mailing Address - Country:US
Mailing Address - Phone:559-228-5448
Mailing Address - Fax:559-224-3920
Practice Address - Street 1:729 NORTH MEDICAL CENTER DRIVE WEST
Practice Address - Street 2:SUITE 101
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6880
Practice Address - Country:US
Practice Address - Phone:559-439-7633
Practice Address - Fax:559-439-7631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83773207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ25114ZMedicare PIN