Healthcare Provider Details

I. General information

NPI: 1396805685
Provider Name (Legal Business Name): ROBERT STORM CILLEY MED, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 ELIZABETH ST
OGDENSBURG NY
13669-3425
US

IV. Provider business mailing address

933 ELIZABETH ST
OGDENSBURG NY
13669-3425
US

V. Phone/Fax

Practice location:
  • Phone: 315-393-1700
  • Fax: 315-393-1700
Mailing address:
  • Phone: 315-393-1700
  • Fax: 315-393-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number056475
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000288-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: