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NPI Code Detail

MEDICARE: SILVER LAKE MEDICAL, PC

MEDICARE: SILVER LAKE MEDICAL, PC
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
1207Q00000XFamily Medicine Physician
2208VP0000XPain Medicine Physician25MB05752300NJ

General Provider Information

NPI Number : 1750875589
Entity Type Code : Organization
Provider Name (Legal Business Name) : SILVER LAKE MEDICAL, PC
Provider Business Mailing Address
First Line : PO BOX 599
Second Line :
City : ROSELAND
State : NJ
Zip : 07068-0599
Country : US
Telephone Number : 973-901-1515
Fax Number :
Provider Business Practice Location Address
First Line : 727 JORALEMON ST
Second Line :
City : BELLEVILLE
State : NJ
Zip : 07109-1455
Country : US
Telephone Number : 973-751-2060
Fax Number : 973-751-2291
Authorized Official
Title or Position : MEDICAL DIRECTOR
Name : ANTONIO CICCONE
Credential : DO
Telephone Number : 973-751-2060
Provider Enumeration Date : 06/15/2018
Last Update Date : 06/15/2018

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Directions to “SILVER LAKE MEDICAL, PC ” Practice Location

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