MEDICARE: DR. MARY SICILIANO D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MB62184	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205834454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY SICILIANO D.O.

Provider Business Mailing Address
First Line	:	PO BOX 27957
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0957
Country	:	US
Telephone Number	:	908-835-1910
Fax Number	:	908-835-1924

Provider Business Practice Location Address
First Line	:	755 MEMORIAL PKWY
Second Line	:	SUITE 300
City	:	PHILLIPSBURG
State	:	NJ
Zip	:	08865-2748
Country	:	US
Telephone Number	:	908-454-6303
Fax Number	:	908-454-2289

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	09/14/2015

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