MEDICARE: DR. BARRY P SIEGEL O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046-006370	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	206874	OTHER		MEDICARE GROUP ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	00105852285	OTHER	AETNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	363727344	OTHER	TAX ID

General Provider Information

NPI Number	:	1639177694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BARRY P SIEGEL O.D.

Provider Business Mailing Address
First Line	:	1926 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2408
Country	:	US
Telephone Number	:	773-525-0952
Fax Number	:	773-525-0966

Provider Business Practice Location Address
First Line	:	1926 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2408
Country	:	US
Telephone Number	:	773-525-0952
Fax Number	:	773-525-0966

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	01/06/2014

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