Provider Demographics
NPI:1942233630
Name:PICONE, SAMUEL B JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:B
Last Name:PICONE
Suffix:JR
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 130
Mailing Address - Street 2:
Mailing Address - City:SUMMIT LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54485-0130
Mailing Address - Country:US
Mailing Address - Phone:715-443-4329
Mailing Address - Fax:815-366-3349
Practice Address - Street 1:N9781 W DUCK LAKE RD # KTC130
Practice Address - Street 2:
Practice Address - City:SUMMIT LAKE
Practice Address - State:WI
Practice Address - Zip Code:54485-9629
Practice Address - Country:US
Practice Address - Phone:715-443-4329
Practice Address - Fax:815-366-3349
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33904208600000X
CAG037968208600000X
PAMD072888L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31885600Medicaid
WIB56162Medicare UPIN
WI001239049Medicare ID - Type Unspecified