Provider Demographics
NPI:1275578262
Name:SIEGEL, ERIC SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:SCOTT
Last Name:SIEGEL
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 1:12 EAST WILLOW STREET
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041
Mailing Address - Country:US
Mailing Address - Phone:973-376-8500
Mailing Address - Fax:973-376-1820
Practice Address - Street 1:12 EAST WILLOW STREET
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1417
Practice Address - Country:US
Practice Address - Phone:973-376-8500
Practice Address - Fax:973-376-1820
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA68842207N00000X
NJ25MA06884200207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2299713OtherAETNA GROUP ID
NJ223694845OtherHORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY
NJ519248Medicare PIN
519248Medicare PIN
G94198Medicare UPIN
NJ2299713OtherAETNA GROUP ID