Healthcare Provider Details

I. General information

NPI: 1306821525
Provider Name (Legal Business Name): JON L SIEGEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

PO BOX 1746
INDIANAPOLIS IN
46206-1746
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-4440
  • Fax:
Mailing address:
  • Phone: 877-383-4442
  • Fax: 678-553-7793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number034243
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number034243
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: