Provider Demographics
NPI:1255363255
Name:SIMON, BRIAN SCOTT (PT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:SCOTT
Last Name:SIMON
Suffix:
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 1:187 MILLBURN AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1847
Mailing Address - Country:US
Mailing Address - Phone:973-467-7976
Mailing Address - Fax:973-467-7971
Practice Address - Street 1:1325 WARREN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:SPRING LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07762-2566
Practice Address - Country:US
Practice Address - Phone:732-449-7855
Practice Address - Fax:732-449-7856
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00778500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ088150TPGMedicare ID - Type Unspecified