Provider Demographics
NPI:1780346254
Name:CLIFFORD, SIMON MARK (MB BCH BAO)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:MARK
Last Name:CLIFFORD
Suffix:
Gender:M
Credentials:MB BCH BAO
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Mailing Address - Street 1:1815 JFK BLVD APT 1519
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1713
Mailing Address - Country:US
Mailing Address - Phone:215-821-4181
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PALT0008802085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology