Provider Demographics
NPI:1053380774
Name:MARTIN-SIMMERMAN, PHYLLIS (MD)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:MARTIN-SIMMERMAN
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 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:253 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1501
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8335
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029841A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100088630Medicaid
IN9274775OtherPHCS PID NUMBER
IN000000183094OtherANTHEM PROVIDER NUMBER
IN10825553OtherCAQH NUMBER
INMA15766030Medicaid
IN100088630Medicaid
IN870630KMedicare PIN
IN142080EEEMedicare PIN
IN10825553OtherCAQH NUMBER
IN300085766Medicare PIN
IN185510KKMedicare PIN
IN815510JJMedicare PIN
IN000000183094OtherANTHEM PROVIDER NUMBER
IN815500IIMedicare PIN
IN815520OOMedicare PIN