MEDICARE: DR. MICHAEL L CICCOLO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	9463	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225165632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL L CICCOLO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 100744
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-0744
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 S MARYLAND PKWY STE 220
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-2424
Country	:	US
Telephone Number	:	702-961-9290
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	03/07/2025

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