Provider Demographics
NPI:1528487436
Name:CICCOTTI, MICHAEL CHRISTOPHER (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHRISTOPHER
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 1:9501 ROOSEVELT BLVD FL 4
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1019
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11173500207X00000X
IL036153327207X00000X, 207XX0005X
PAMD474669207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine