Provider Demographics
NPI:1780423640
Name:SIEGEL, CHARLES GRAHAM (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:GRAHAM
Last Name:SIEGEL
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 1:3509 NORTH BROAD STREET
Mailing Address - Street 2:BOYER SUITE 226
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4105
Mailing Address - Country:US
Mailing Address - Phone:215-707-9837
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:800-836-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT231114207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine