=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396364592
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARISSA CICCHINELLI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2020
-----------------------------------------------------
Last Update Date | 07/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 WALNUT ST STE 601
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-5563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-3523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 229 E FRONT ST
-----------------------------------------------------
City | MEDIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19063-3035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-226-6692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD480664
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------