Provider Demographics
NPI:1851315444
Name:SICARD, G R (MD)
Entity Type:Individual
Prefix:DR
First Name:G
Middle Name:R
Last Name:SICARD
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 1:4825 MUNSON STREET NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3690
Mailing Address - Country:US
Mailing Address - Phone:330-497-7525
Mailing Address - Fax:330-497-2687
Practice Address - Street 1:4825 MUNSON STREET NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3690
Practice Address - Country:US
Practice Address - Phone:330-497-7525
Practice Address - Fax:330-497-2687
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35031404S174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121255Medicaid
OH0121255Medicaid
OHSI0150222Medicare ID - Type UnspecifiedINDIVIDUAL