Provider Demographics
NPI:1366453466
Name:SIEGFRIED, BRYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:SIEGFRIED
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 1:444 N EDWARDSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-1334
Mailing Address - Country:US
Mailing Address - Phone:618-635-3800
Mailing Address - Fax:618-307-6130
Practice Address - Street 1:444 N EDWARDSVILLE ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:IL
Practice Address - Zip Code:62088-1334
Practice Address - Country:US
Practice Address - Phone:618-635-3800
Practice Address - Fax:618-307-6130
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK18060Medicare PIN
ILH66430Medicare UPIN