Provider Demographics
NPI:1720063613
Name:ICELY, SUZANNE T (MD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:T
Last Name:ICELY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 CENTRAL AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8502
Mailing Address - Country:US
Mailing Address - Phone:727-767-6060
Mailing Address - Fax:727-767-1285
Practice Address - Street 1:5959 CENTRAL AVE STE 103
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-8502
Practice Address - Country:US
Practice Address - Phone:727-767-6060
Practice Address - Fax:727-767-1285
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071624207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255805000Medicaid
FL43530Medicare ID - Type Unspecified
FL255805000Medicaid