Basic Information
| Provider Information | |||||||||
| NPI: | 1952332132 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIEGEL | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1830 BLAKE AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD SPGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816014261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703847144 | ||||||||
| FaxNumber: | 9703848115 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 23RD ST STE 6 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064082820 | ||||||||
| FaxNumber: | 6063260235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 30428 | CO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 9401492 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | C0054 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 142AG | 01 | NC | BCBSNC | OTHER |