Basic Information
Provider Information | |||||||||
NPI: | 1215248711 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIEGALL | ||||||||
FirstName: | EVAN | ||||||||
MiddleName: | MATTHEW | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 191 | ||||||||
Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
City: | ROCKLAND | ||||||||
State: | DE | ||||||||
PostalCode: | 197320191 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6026516212 | ||||||||
FaxNumber: | 3026514945 | ||||||||
Practice Location | |||||||||
Address1: | 4425 PAULSEN ST | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314053662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123556615 | ||||||||
FaxNumber: | 9123510645 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2010 | ||||||||
LastUpdateDate: | 05/31/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4244 | GA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XP3100X | ME124350 | FL | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
No ID Information.