Basic Information
Provider Information | |||||||||
NPI: | 1508185349 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIEGEL | ||||||||
FirstName: | ZACHARY | ||||||||
MiddleName: | TIMOTHY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 411 PLAZA DR | ||||||||
Address2: | SUITE H | ||||||||
City: | COLUMBUS | ||||||||
State: | IN | ||||||||
PostalCode: | 472012916 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123765974 | ||||||||
FaxNumber: | 8123753203 | ||||||||
Practice Location | |||||||||
Address1: | 2400 17TH ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | IN | ||||||||
PostalCode: | 472015351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123765974 | ||||||||
FaxNumber: | 8123753203 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2010 | ||||||||
LastUpdateDate: | 04/22/2016 | ||||||||
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 | 2081N0008X | 01073329A | IN | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Neuromuscular Medicine | 208100000X | 1073329A | IN | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 2081P0004X | 1073329A | IN | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Spinal Cord Injury Medicine | 2081S0010X | 1073329A | IN | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 201110840 | 05 | IN |   | MEDICAID | 000000991156 | 01 |   | ANTHEM PIN | OTHER |