Provider Demographics
NPI:1790746790
Name:LICO, SERRIE C (MD)
Entity Type:Individual
Prefix:
First Name:SERRIE
Middle Name:C
Last Name:LICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 MERCY DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2614
Mailing Address - Country:US
Mailing Address - Phone:330-489-1000
Mailing Address - Fax:
Practice Address - Street 1:1330 MERCY DR NW STE 101
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2624
Practice Address - Country:US
Practice Address - Phone:330-588-4676
Practice Address - Fax:330-588-4677
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10202300208G00000X
PAMD068831L208G00000X
OH35.122143208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03112934Medicaid
G47469Medicare UPIN
G47469Medicare UPIN
PA028742Medicare ID - Type Unspecified