Basic Information
| Provider Information | |||||||||
| NPI: | 1538375274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIEGEL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6476 BORR AVE | ||||||||
| Address2: | |||||||||
| City: | REYNOLDSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430681645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144028700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4420 REFUGEE RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432324416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148392150 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | AT-1141 | OH | Y | Other Service Providers | Legal Medicine |
No ID Information.