Basic Information
| Provider Information | |||||||||
| NPI: | 1710974753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIEGEL | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6025 LAKE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519996800 | ||||||||
| FaxNumber: | 6519996800 | ||||||||
| Practice Location | |||||||||
| Address1: | 6025 LAKE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519996800 | ||||||||
| FaxNumber: | 6519996800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 09/15/2014 | ||||||||
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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 | 208800000X | 36114 | MN | Y | Allopathic & Osteopathic Physicians | Urology | 2088F0040X | 36114 | MN | N | Allopathic & Osteopathic Physicians | Urology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 651862100 | 05 | MN | MEDICAID |