Provider Demographics
NPI:1154652576
Name:MARINA V KULICK MD PLC
Entity Type:Organization
Organization Name:MARINA V KULICK MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PRESIDNT
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:V
Authorized Official - Last Name:KULICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-940-3478
Mailing Address - Street 1:1744 S PINELLAS AVE
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-1939
Mailing Address - Country:US
Mailing Address - Phone:727-940-3478
Mailing Address - Fax:727-940-3480
Practice Address - Street 1:1744 S PINELLAS AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-1939
Practice Address - Country:US
Practice Address - Phone:727-940-3478
Practice Address - Fax:727-940-3480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QA0505X
FLME1034992083P0500X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CY553AOtherPTAN
FL001860000Medicaid