Healthcare Provider Details

I. General information

NPI: 1326268491
Provider Name (Legal Business Name): MICHAEL FRANCIS CICCARELLI JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 NEW SCOTLAND AVENUE ALBANY MEDICAL CENTER
ALBANY NY
12208
US

IV. Provider business mailing address

3 EDWARD DR
WEST SAND LAKE NY
12196-9789
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-4050
  • Fax:
Mailing address:
  • Phone: 518-674-0804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number241890
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: