Provider Demographics
NPI:1619919313
Name:KEGEL, JEFFREY GLEN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:GLEN
Last Name:KEGEL
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:PO BOX 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-6335
Mailing Address - Country:US
Mailing Address - Phone:215-831-2355
Mailing Address - Fax:215-831-2017
Practice Address - Street 1:5 FOUNDERS ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226
Practice Address - Country:US
Practice Address - Phone:860-456-2898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT35405207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA698880OtherHIGHMARK BLUE SHIELD
PA3513564000OtherKEYSTONE IBC
PA30062352OtherKEYSTONE MERCY
PA0014547140005Medicaid
PA41478MD045251EOtherHEALTH PARTNERS
PA5989452OtherAETNA PPO
PA6887720OtherAETNA HMO
PA698880OtherHIGHMARK BLUE SHIELD
PA0014547140005Medicaid
PA134433Medicare PIN