Provider Demographics
NPI:1043589187
Name:ANTHONY P. NICOSIA MD LLC
Entity Type:Organization
Organization Name:ANTHONY P. NICOSIA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:NICOSIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-332-1757
Mailing Address - Street 1:PO BOX 8540
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-8540
Mailing Address - Country:US
Mailing Address - Phone:772-332-1757
Mailing Address - Fax:772-335-9843
Practice Address - Street 1:1502 SE HOLIDAY RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5416
Practice Address - Country:US
Practice Address - Phone:772-332-1757
Practice Address - Fax:772-335-9843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2013-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278035600Medicaid
FL91967OtherBLUE CROSS
FLP00476573OtherRRMCR#
FLD06752Medicare UPIN
FL91967OtherBLUE CROSS
FLU4211ZMedicare PIN