Provider Demographics
NPI:1336426337
Name:SIEGEL, HOWARD WAYNE
Entity Type:Individual
Prefix:MR
First Name:HOWARD
Middle Name:WAYNE
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 SHERIDAN ROAD
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1363
Mailing Address - Country:US
Mailing Address - Phone:847-835-1566
Mailing Address - Fax:847-835-0356
Practice Address - Street 1:12700 W ROCKLAND
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044
Practice Address - Country:US
Practice Address - Phone:847-615-2088
Practice Address - Fax:847-615-2177
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051028862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist