=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396877841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD SIEGEL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2007
-----------------------------------------------------
Last Update Date | 07/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 E CHURCH ST
-----------------------------------------------------
City | SANTA MARIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93454-5906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-434-4989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1510
-----------------------------------------------------
City | TEMPLETON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93465-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-434-4989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | G19183
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------