Provider Demographics
NPI:1265486336
Name:SIEGAN, MITCHELL J (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:J
Last Name:SIEGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 DALTON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-7959
Mailing Address - Country:US
Mailing Address - Phone:843-402-1000
Mailing Address - Fax:
Practice Address - Street 1:2095 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5733
Practice Address - Country:US
Practice Address - Phone:843-402-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21770207L00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT59503Medicaid
SCT59503Medicaid
SCT59503Medicaid
BS6279598OtherDEA