Provider Demographics
NPI:1295822716
Name:CICERO MEDICAL CLINICA SAN LAZARO LLC
Entity Type:Organization
Organization Name:CICERO MEDICAL CLINICA SAN LAZARO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LICEA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:708-656-5485
Mailing Address - Street 1:5712 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-4222
Mailing Address - Country:US
Mailing Address - Phone:708-656-5485
Mailing Address - Fax:708-656-5657
Practice Address - Street 1:5712 W 35TH ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-4222
Practice Address - Country:US
Practice Address - Phone:708-656-5485
Practice Address - Fax:708-656-5657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDF0534OtherRAILROAD MEDICARE
IL0179982OtherHEALTHSPRING
IL1636532OtherBLUE CROSS BLUE SHIELD
IL214075Medicare PIN