Healthcare Provider Details

I. General information

NPI: 1689663239
Provider Name (Legal Business Name): ROGER S CICALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6325 HUMPHREYS BLVD
MEMPHIS TN
38120-2300
US

IV. Provider business mailing address

6325 HUMPHREYS BLVD
MEMPHIS TN
38120-2300
US

V. Phone/Fax

Practice location:
  • Phone: 901-522-7700
  • Fax: 901-522-2550
Mailing address:
  • Phone: 901-522-7700
  • Fax: 901-522-2550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD14415
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: