Provider Demographics
NPI:1528020898
Name:CICILLINE, MICHELLE SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUSAN
Last Name:CICILLINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 278980
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 RED CREEK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-5264
Practice Address - Country:US
Practice Address - Phone:585-334-0130
Practice Address - Fax:585-334-0213
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059841207Q00000X
NY253287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03135797Medicaid
NYJ400004741Medicare PIN
NY03135797Medicaid
MD089LG150Medicare ID - Type Unspecified