Provider Demographics
NPI:1720007719
Name:CICONE, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:CICONE
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 1:5301 E HURON RIVER DR
Mailing Address - Street 2:MC 69504
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1051
Mailing Address - Country:US
Mailing Address - Phone:734-827-8883
Mailing Address - Fax:734-827-8915
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:SUITE 5115
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1014
Practice Address - Country:US
Practice Address - Phone:734-712-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBC404905207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN53240024Medicare PIN