Provider Demographics
NPI:1093036659
Name:SERRIE C. LICO MD, CARDIOVASCULAR & THORACIC SURGERY PC
Entity Type:Organization
Organization Name:SERRIE C. LICO MD, CARDIOVASCULAR & THORACIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SERRIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:LICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-821-7714
Mailing Address - Street 1:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-0024
Mailing Address - Country:US
Mailing Address - Phone:716-821-7714
Mailing Address - Fax:716-821-7716
Practice Address - Street 1:515 ABBOTT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-1700
Practice Address - Country:US
Practice Address - Phone:716-821-7714
Practice Address - Fax:716-821-7716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184556-1208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G47469Medicare UPIN