Basic Information
| Provider Information | |||||||||
| NPI: | 1508976663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIEGEL | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9210 GOLF COURSE RD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871145891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052982505 | ||||||||
| FaxNumber: | 5052982985 | ||||||||
| Practice Location | |||||||||
| Address1: | 9210 GOLF COURSE RD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871145891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052982505 | ||||||||
| FaxNumber: | 5052982985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD2015-0741 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 376613600 | 05 | FL | MEDICAID |