Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | 036-067302 | IL |
NPI | 1205861945 |
---|---|
Provider Name | Mr. Michael D Siegel |
First Address | Lake Forest, IL 60045 |
Second Address | Highland Park, IL 60035 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2006 |
Last Update Date | 22/01/2013 |