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General NPI Number Information
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NPI Number | 1942233630
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Entity Type | Individual
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Provider Name | SAMUEL B PICONE JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/08/2006
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Last Update Date | 01/06/2014
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Provider Practice Location Address
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Address Line | N9781 W DUCK LAKE RD # KTC130
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City | SUMMIT LAKE
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State | WI
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Zip | 54485-9629
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Country | US
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Telephone | 715-443-4329
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Fax | 815-366-3349
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Provider Business Mailing Address
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Address Line | PO BOX 130
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City | SUMMIT LAKE
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State | WI
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Zip | 54485-0130
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Country | US
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Telephone | 715-443-4329
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Fax | 815-366-3349
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 33904
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | G037968
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MD072888L
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License Number State | PA
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