Provider Demographics
NPI:1114972536
Name:SIEGEL, JENNIFER A (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 NORTH ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901
Mailing Address - Country:US
Mailing Address - Phone:618-833-1691
Mailing Address - Fax:618-503-0688
Practice Address - Street 1:2250 NORTH ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-833-1691
Practice Address - Fax:618-503-0688
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54919207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A549190Medicaid
CA00A549190OtherBLUE SHIELD
CAG84872Medicare UPIN
CA00A549190Medicaid