Provider Demographics
NPI:1518945567
Name:RICCIONE, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:RICCIONE
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 1:1000 E GENESEE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1892
Mailing Address - Country:US
Mailing Address - Phone:315-269-9729
Mailing Address - Fax:315-472-3712
Practice Address - Street 1:1000 E GENESEE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1892
Practice Address - Country:US
Practice Address - Phone:315-472-8835
Practice Address - Fax:315-476-3712
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168710174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01416802Medicaid
NY00157670Medicaid
300063512Medicare PIN
NY01416802Medicaid
NY52931FMedicare PIN
NY55459IMedicare PIN