Provider Demographics
NPI:1558322917
Name:SICILIANO, GERARD V (MD)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:V
Last Name:SICILIANO
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3999 DUTCHMANS LN
Practice Address - Street 2:SUITE 7B
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4729
Practice Address - Country:US
Practice Address - Phone:502-896-4711
Practice Address - Fax:502-896-4791
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32151208600000X, 174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201080170Medicaid
KY000000049918OtherANTHEM PIN #
KY64321516Medicaid
KY50034545OtherPASSPORT- NORTON SURGICAL SPECIALISTS
KY64321516Medicaid
KY000000049918OtherANTHEM PIN #
KY253903Medicare ID - Type Unspecified