Basic Information
| Provider Information | |||||||||
| NPI: | 1679765481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEGAL | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 62681 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212642681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816577 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 BESTGATE RD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108970822 | ||||||||
| FaxNumber: | 4108970095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 10/21/2013 | ||||||||
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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 | 207R00000X | D0056089 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | D0056089 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 074931101 | 05 | MD | MEDICAID |