Basic Information
| Provider Information | |||||||||
| NPI: | 1790767440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CICCONE | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9142 | ||||||||
| Address2: | MASS GENERAL PHYSICIAN ORGANIZATION | ||||||||
| City: | CHARLESTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021299142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177240287 | ||||||||
| FaxNumber: | 6177262894 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | MASSACHUSETTS GENERAL HOSPITAL NEW BORN SERVICE FND 442 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177249040 | ||||||||
| FaxNumber: | 6177269346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 12/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 81978 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 081978 | 01 | MA | TUFTS HEALTH PLAN | OTHER | J17479 | 01 | MA | BCBS MA | OTHER | 3151034 | 05 | MA | MEDICAID |