Provider Demographics
NPI:1952397192
Name:SIMON, ELISABETH (MD)
Entity Type:Individual
Prefix:PROF
First Name:ELISABETH
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 NEW SCOTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:518-262-9440
Mailing Address - Fax:518-262-9443
Practice Address - Street 1:47 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-9440
Practice Address - Fax:518-262-9443
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1936912080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00146478Medicaid
NYDD3128Medicare ID - Type Unspecified
NY00146478Medicaid