Healthcare Provider Details

I. General information

NPI: 1477046092
Provider Name (Legal Business Name): THE GOUT INSTITUTE OF AMERICA AT BELLEVILLE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 JORALEMON ST
BELLEVILLE NJ
07109-1455
US

IV. Provider business mailing address

727 JORALEMON ST
BELLEVILLE NJ
07109-1455
US

V. Phone/Fax

Practice location:
  • Phone: 973-751-2060
  • Fax: 973-751-2291
Mailing address:
  • Phone: 973-751-2060
  • Fax: 973-751-2291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number25MB05752300
License Number StateNJ

VIII. Authorized Official

Name: ANTONIO CICCONE
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 973-751-2060