Basic Information
| Provider Information | |||||||||
| NPI: | 1730144296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CICCHIELLO | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 7926 PRESTON HWY | ||||||||
| Address2: | STE 210 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402193848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029668675 | ||||||||
| FaxNumber: | 5029668836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 11/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 26217 | KY | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 2448315000 | 01 | PAD - NMA | OTHER | 64262173 | 05 | KY | MEDICAID | 1193582 | 01 | CHA / NMA | OTHER | P00266880 | 01 | KY | RRMCR - NMA | OTHER | 000000364343 | 01 | ANTHEM - NMA | OTHER | 000000720334 | 01 | KY | ANTHEM - ICC | OTHER | 0724045 | 01 | CIGNA / NMA | OTHER | 50007142 | 01 | PASSPORT - NMA | OTHER | 0000023025F | 01 | HUMANA / NMA | OTHER | 062447 | 01 | SIHO - NMA | OTHER |