1750378824 NPI number — JOHN M CICCONE MD

Table of content: JOHN M CICCONE MD (NPI 1750378824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750378824 NPI number — JOHN M CICCONE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CICCONE
Provider First Name:
JOHN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750378824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751649
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-789-1620
Provider Business Mailing Address Fax Number:
843-724-2454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3510 HWY 17 NORTH
Provider Second Line Business Practice Location Address:
STE 325
Provider Business Practice Location Address City Name:
MT. PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29466-8232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-606-8982
Provider Business Practice Location Address Fax Number:
843-606-8077
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  MA37832 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 34588 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1K9389 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: ES226 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0963382002 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1075758 . This is a "HORIZON MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1747304 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4094234 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 81554 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010000347500 . This is a "AMERICHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0199893000 . This is a "AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5710570 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 28F431 . This is a "WELLCHOICE" identifier . This identifiers is of the category "OTHER".




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