Provider Demographics
NPI:1639245368
Name:SEGALL, KEITH EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:SEGALL
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 1:111 PARKWAY
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:MO
Mailing Address - Zip Code:65582-8003
Mailing Address - Country:US
Mailing Address - Phone:573-422-3360
Mailing Address - Fax:573-422-3391
Practice Address - Street 1:111 PARKWAY
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:MO
Practice Address - Zip Code:65582-8003
Practice Address - Country:US
Practice Address - Phone:573-422-3360
Practice Address - Fax:573-422-3391
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOD0106518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10048OtherBLUE CROSS
1904V1471OtherHEALTHCARE USA
MOG00218OtherMERCY HEALTH PLAN
MOV410OtherMISSOURI CARE
0120039OtherUNITED HEALTHCARE
13680OtherGROUP HEALTH PLAN
MO247757602Medicaid
MO257668OtherHEALTHLINK
MOG00218OtherMERCY HEALTH PLAN
G00218Medicare UPIN