Healthcare Provider Details

I. General information

NPI: 1639245368
Provider Name (Legal Business Name): KEITH EDWARD SEGALL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PARKWAY
VIENNA MO
65582-8003
US

IV. Provider business mailing address

111 PARKWAY
VIENNA MO
65582-8003
US

V. Phone/Fax

Practice location:
  • Phone: 573-422-3360
  • Fax: 573-422-3391
Mailing address:
  • Phone: 573-422-3360
  • Fax: 573-422-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0106518
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: