Healthcare Provider Details

I. General information

NPI: 1265446157
Provider Name (Legal Business Name): ELLIOTT GERALD SEGAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126B SEWALL AVE
BROOKLINE MA
02446-5327
US

IV. Provider business mailing address

126B SEWALL AVE
BROOKLINE MA
02446-5327
US

V. Phone/Fax

Practice location:
  • Phone: 617-734-8231
  • Fax:
Mailing address:
  • Phone: 617-734-8231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number28902
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: