Healthcare Provider Details

I. General information

NPI: 1184714586
Provider Name (Legal Business Name): KRISTINA CICCOTELLI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 HUNTINGDON PIKE
HUNTINGDON VALLEY PA
19006
US

IV. Provider business mailing address

1650 HUNTINGDON PIKE SUITE 313
MEADOWBROOK PA
19046-8007
US

V. Phone/Fax

Practice location:
  • Phone: 215-938-3413
  • Fax: 215-938-3122
Mailing address:
  • Phone: 215-938-3413
  • Fax: 215-938-3422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD049754L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: