Basic Information
| Provider Information | |||||||||
| NPI: | 1992735443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIEGEL | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 2ND AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100032746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127348874 | ||||||||
| FaxNumber: | 2122495628 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 2ND AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100032746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127348874 | ||||||||
| FaxNumber: | 2122495628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 08/20/2015 | ||||||||
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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 | 207RG0100X | 0902980 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 00142636 | 05 | NY | MEDICAID |