Provider Demographics
NPI:1619982444
Name:SEGALL, NATHAN (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:SEGALL
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 1:175 COUNTRY CLUB DR 100A
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7380
Mailing Address - Country:US
Mailing Address - Phone:404-705-9170
Mailing Address - Fax:770-507-1539
Practice Address - Street 1:175 COUNTRY CLUB DR 100A
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7380
Practice Address - Country:US
Practice Address - Phone:770-507-0707
Practice Address - Fax:770-507-1539
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020602207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000219161EMedicaid
GAD30764Medicare UPIN
GA000219161EMedicaid