Provider Demographics
NPI:1942260641
Name:SIEGFELD, ALISA SUE (MD)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:SUE
Last Name:SIEGFELD
Suffix:
Gender:F
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 230
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-0230
Mailing Address - Country:US
Mailing Address - Phone:860-633-8806
Mailing Address - Fax:860-657-8378
Practice Address - Street 1:124 HEBRON AVE STE 1B
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2066
Practice Address - Country:US
Practice Address - Phone:860-633-8806
Practice Address - Fax:860-657-3788
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT335442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010033544CT12OtherANTHEM BC/BS
CT300101740OtherRAILROAD MEDICARE
CT300117749OtherRAILROAD MEDICARE
CT300117771OtherRAILROAD MEDICARE
CT010033544CT14OtherANTHEM BC/BS
CT010033544CT06OtherANTHEM BC/BS
CT010033544CT08OtherANTHEM BC/BS
CT300117754OtherRAILROAD MEDICARE
CT001335448Medicaid
CT010033544CT03OtherANTHEM BC/BS
CT010033544CT13OtherANTHEM BC/BS
CT300110158OtherRAILROAD MEDICARE
CT300110158OtherRAILROAD MEDICARE
CT300002029Medicare PIN
CT300002030Medicare PIN
CT300117749OtherRAILROAD MEDICARE
CT300002031Medicare PIN
CT001335448Medicaid
CT300117771OtherRAILROAD MEDICARE
CT010033544CT08OtherANTHEM BC/BS
CT300003020Medicare ID - Type Unspecified