Provider Demographics
NPI:1356316178
Name:SIEGEL, MARC S (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:S
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 1:120 PROFESSIONAL PARK DR
Mailing Address - Street 2:STE 7
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060
Mailing Address - Country:US
Mailing Address - Phone:540-552-3601
Mailing Address - Fax:540-552-7585
Practice Address - Street 1:120 PROFESSIONAL PARK DR
Practice Address - Street 2:STE 7
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060
Practice Address - Country:US
Practice Address - Phone:540-552-3601
Practice Address - Fax:540-552-7585
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036792207X00000X, 207XX0004X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1356316178Medicaid
B08175Medicare UPIN
VA1356316178Medicaid
0635320001Medicare NSC
VA200000202Medicare ID - Type Unspecified
VAP01003044Medicare PIN