Provider Demographics
NPI:1629020326
Name:SIEGEL, SCOTT ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALAN
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 BLACKLOG RD
Mailing Address - Street 2:
Mailing Address - City:INEZ
Mailing Address - State:KY
Mailing Address - Zip Code:41224-9113
Mailing Address - Country:US
Mailing Address - Phone:606-534-3435
Mailing Address - Fax:606-534-3436
Practice Address - Street 1:3165 BLACKLOG RD
Practice Address - Street 2:
Practice Address - City:INEZ
Practice Address - State:KY
Practice Address - Zip Code:41224-9113
Practice Address - Country:US
Practice Address - Phone:606-534-3435
Practice Address - Fax:606-534-3436
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102207660207Q00000X
KY04666207Q00000X
WV1939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVH62788Medicare UPIN