Healthcare Provider Details

I. General information

NPI: 1659347904
Provider Name (Legal Business Name): ITA S SEGAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 GOLD STAR BLVD
WORCESTER MA
01606
US

IV. Provider business mailing address

630 PLANTATION ST WOT 12TH FLOOR ATTN PHYSICIAN SERVICES
WORCESTER MA
01605
US

V. Phone/Fax

Practice location:
  • Phone: 508-853-2716
  • Fax: 508-856-9025
Mailing address:
  • Phone: 508-368-5529
  • Fax: 508-368-5530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number030717
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierAA39601
Identifier TypeOTHER
Identifier State
Identifier IssuerHARVARD PILGRIM HEALTHCAR
# 2
Identifier042472266
Identifier TypeOTHER
Identifier State
Identifier IssuerONE HEALTH PLAN
# 3
Identifier042472266
Identifier TypeOTHER
Identifier State
Identifier IssuerPRIVATE HEALTHCARE SYSTEM
# 4
Identifier2110458
Identifier TypeOTHER
Identifier State
Identifier IssuerWELFARE
# 5
Identifier77954
Identifier TypeOTHER
Identifier State
Identifier IssuerFALLON COMMUNITY HEALTH P
# 6
Identifier2110458
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 7
Identifier347461
Identifier TypeOTHER
Identifier State
Identifier IssuerTUFTS HEALTH PLAN
# 8
IdentifierJ29502
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE CARE ELECT
# 9
Identifier786705
Identifier TypeOTHER
Identifier State
Identifier IssuerMVP HEALTH CARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: