Healthcare Provider Details

I. General information

NPI: 1831366582
Provider Name (Legal Business Name): MICHAEL L CICCHESE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 METRO CENTER BLVD STE 200
WARWICK RI
02886-1768
US

IV. Provider business mailing address

125 METRO CENTER BLVD STE 2000
WARWICK RI
02886-1768
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-2520
  • Fax: 401-453-8220
Mailing address:
  • Phone: 401-432-2520
  • Fax: 401-453-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number235803
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number12926
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: