Healthcare Provider Details

I. General information

NPI: 1679765481
Provider Name (Legal Business Name): JEROME SEGAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 10/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 BESTGATE RD SUITE 208
ANNAPOLIS MD
21401-3091
US

IV. Provider business mailing address

PO BOX 62681
BALTIMORE MD
21264-2681
US

V. Phone/Fax

Practice location:
  • Phone: 410-897-0822
  • Fax: 410-897-0095
Mailing address:
  • Phone: 443-481-6577
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0056089
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD0056089
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: