Provider Demographics
NPI:1881687721
Name:CICCARELLI, CLEM ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:CLEM
Middle Name:ANTHONY
Last Name:CICCARELLI
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 1:503 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:NEW CUMBERLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17070-1972
Mailing Address - Country:US
Mailing Address - Phone:717-774-8400
Mailing Address - Fax:717-774-8607
Practice Address - Street 1:503 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:NEW CUMBERLAND
Practice Address - State:PA
Practice Address - Zip Code:17070-1972
Practice Address - Country:US
Practice Address - Phone:717-774-8400
Practice Address - Fax:717-774-8607
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025514E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA091165F6KMedicare PIN
PA091165F6KMedicare PIN