Basic Information
| Provider Information | |||||||||
| NPI: | 1104114875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEGAL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 CROSSROADS DR | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437382872 | ||||||||
| FaxNumber: | 4437382713 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 LOCH RAVEN BLVD | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212392945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104337303 | ||||||||
| FaxNumber: | 4104337755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2011 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | D0074546 | MD | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3354580 00 | 05 | MD | MEDICAID |