Provider Demographics
NPI:1245287556
Name:CICCOTTI, MICHAEL GIRARD (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GIRARD
Last Name:CICCOTTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:609-677-7003
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:267-339-3500
Practice Address - Fax:215-503-0580
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040661E207XX0005X, 207X00000X
NJ25MA06744600207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0116226OtherAETNA
PA0529117000OtherIBC
1260028OtherCIGNA
PA200025817Medicare PIN
1260028OtherCIGNA
PA0529117000OtherIBC
PA694143GC6Medicare ID - Type Unspecified