Healthcare Provider Details

I. General information

NPI: 1457691628
Provider Name (Legal Business Name): PATRICK EDWIN CICCONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 CHERRY ST 12E
PHILADELPHIA PA
19103-1029
US

IV. Provider business mailing address

2301 CHERRY ST 12E
PHILADELPHIA PA
19103-1029
US

V. Phone/Fax

Practice location:
  • Phone: 215-801-3081
  • Fax:
Mailing address:
  • Phone: 215-801-3081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberMD012744E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: