Healthcare Provider Details

I. General information

NPI: 1366453466
Provider Name (Legal Business Name): BRYAN SIEGFRIED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 09/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 N EDWARDSVILLE ST
STAUNTON IL
62088-1334
US

IV. Provider business mailing address

444 N EDWARDSVILLE ST
STAUNTON IL
62088-1334
US

V. Phone/Fax

Practice location:
  • Phone: 618-635-3800
  • Fax: 618-307-6130
Mailing address:
  • Phone: 618-635-3800
  • Fax: 618-307-6130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: