Provider Demographics
NPI:1790865178
Name:MICHAEL A CICERO MD PC
Entity Type:Organization
Organization Name:MICHAEL A CICERO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:CICERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-569-9397
Mailing Address - Street 1:106 FAIRVIEW DR STE C
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851-1247
Mailing Address - Country:US
Mailing Address - Phone:757-569-9397
Mailing Address - Fax:757-569-0353
Practice Address - Street 1:106 FAIRVIEW DR STE C
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1247
Practice Address - Country:US
Practice Address - Phone:757-569-9397
Practice Address - Fax:757-569-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA823584OtherMAMSI
VA048159OtherANTHEM
VA67041OtherOPTIMA
NC890505GMedicaid
VA048159OtherANTHEM