Provider Demographics
NPI:1619010170
Name:KAREN JILL CICCARELLI, M.D. PC
Entity Type:Organization
Organization Name:KAREN JILL CICCARELLI, M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:CICCARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-223-4529
Mailing Address - Street 1:16605 KENDLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21795-1614
Mailing Address - Country:US
Mailing Address - Phone:301-223-4529
Mailing Address - Fax:301-223-1240
Practice Address - Street 1:16605 KENDLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795-1614
Practice Address - Country:US
Practice Address - Phone:301-223-4529
Practice Address - Fax:301-223-1240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD464PMedicare PIN