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General NPI Number Information
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NPI Number | 1750875589
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Entity Type | Organization
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Legal Business Name | SILVER LAKE MEDICAL, PC
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Dates
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Enumeration Date | 06/15/2018
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Last Update Date | 06/15/2018
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Provider Practice Location Address
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Address Line | 727 JORALEMON ST
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City | BELLEVILLE
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State | NJ
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Zip | 07109-1455
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Country | US
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Telephone | 973-751-2060
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Fax | 973-751-2291
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Provider Business Mailing Address
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Address Line | PO BOX 599
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City | ROSELAND
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State | NJ
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Zip | 07068-0599
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Country | US
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Telephone | 973-901-1515
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | ANTONIO CICCONE
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Credential | DO
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Telephone | 973-751-2060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | 25MB05752300
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License Number State | NJ
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