# SILVER LAKE MEDICAL, PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1750875589
- **Authorized official:** ANTONIO CICCONE DO (MEDICAL DIRECTOR)
- **Authorized official phone:** (973) 751-2060

## Contact information

- **Practice address:** 727 JORALEMON ST, BELLEVILLE, NJ 07109-1455
- **Practice address phone:** (973) 751-2060
- **Practice address fax:** (973) 751-2291
- **Mailing address:** PO BOX 599, ROSELAND, NJ 07068-0599
- **Mailing address phone:** (973) 901-1515

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 208VP0000X | Pain Medicine Physician | 25MB05752300 | NJ | Yes |

## Other

- **Enumeration date:** 06/15/2018
- **Last updated:** 06/15/2018