Provider Demographics
NPI:1346208238
Name:SIEGEL, CHARLES J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
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 1:6000 N OAK TRFY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-5165
Mailing Address - Country:US
Mailing Address - Phone:816-453-7771
Mailing Address - Fax:816-452-7980
Practice Address - Street 1:6000 N OAK TRFY
Practice Address - Street 2:102
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-5165
Practice Address - Country:US
Practice Address - Phone:816-453-7771
Practice Address - Fax:816-452-7980
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9645174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MON544281Medicare ID - Type Unspecified
MOC50376Medicare UPIN