Basic Information
| Provider Information | |||||||||
| NPI: | 1396785267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEGAL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 DOUGHTY ST | ||||||||
| Address2: | STE 420 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294035741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437233441 | ||||||||
| FaxNumber: | 8438054040 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 DOUGHTY ST | ||||||||
| Address2: | STE 420 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437233441 | ||||||||
| FaxNumber: | 8438054040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/22/2016 | ||||||||
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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 | 207L00000X | 19043 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 190439 | 05 | SC | MEDICAID |