Healthcare Provider Details

I. General information

NPI: 1528020898
Provider Name (Legal Business Name): MICHELLE SUSAN CICILLINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/06/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RED CREEK DR SUITE 100
ROCHESTER NY
14623-5264
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 278980
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-334-0130
  • Fax: 585-334-0213
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0059841
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number253287
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: