Healthcare Provider Details

I. General information

NPI: 1285691576
Provider Name (Legal Business Name): KENNETH M SEGAL D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 HOPE ST
PROVIDENCE RI
02906-2651
US

IV. Provider business mailing address

677 HOPE ST
PROVIDENCE RI
02906-2651
US

V. Phone/Fax

Practice location:
  • Phone: 401-421-7466
  • Fax: 401-751-3883
Mailing address:
  • Phone: 401-421-7466
  • Fax: 401-751-3883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDPM00193
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: