Healthcare Provider Details

I. General information

NPI: 1124019583
Provider Name (Legal Business Name): ROBERT EDWARD CICCHINO JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 WALNUT AVE SUITE A
WAYNESBURG PA
15370-1668
US

IV. Provider business mailing address

112 WALNUT AVE SUITE A
WAYNESBURG PA
15370-1668
US

V. Phone/Fax

Practice location:
  • Phone: 724-627-5474
  • Fax:
Mailing address:
  • Phone: 724-627-5474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOS008378L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2222
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: