Healthcare Provider Details

I. General information

NPI: 1548201569
Provider Name (Legal Business Name): WILLIAM M CICIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 CYPRESS CIR STE 102
CONWAY SC
29526-8964
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD ATTENTION PATIENT ACCOUNTING
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-8953
  • Fax: 843-347-0226
Mailing address:
  • Phone: 843-234-6827
  • Fax: 843-234-6990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME 88048
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD453708
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number83204
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: