Provider Demographics
NPI:1093863532
Name:SIEGENTHALER, MICHAEL P (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:SIEGENTHALER
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 1:30 W MCCREIGHT AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-1853
Mailing Address - Country:US
Mailing Address - Phone:937-523-9825
Mailing Address - Fax:937-523-9829
Practice Address - Street 1:705 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5573
Practice Address - Country:US
Practice Address - Phone:903-315-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430302208G00000X
MDD0068474208G00000X
TXL2653208G00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415096100Medicaid
PA108126Medicare PIN
DC149600Medicare PIN