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Organization
CICERO MEDICAL CLINICA SAN LAZARO LLC
Active
Organization
CICERO MEDICAL CLINICA SAN LAZARO LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GERARD LICEA MBA (REGISTERED AGENT)
(708) 656-5485
Entity
Organization
Contact information
Practice address
5712 W 35TH ST, CICERO, IL 60804-4222
(708) 656-5485
(708) 656-5657
Mailing address
5712 W 35TH ST, CICERO, IL 60804-4222
(708) 656-5485
(708) 656-5657
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0179982
HEALTHSPRING
IL
01
—
1636532
BLUE CROSS BLUE SHIELD
IL
01
—
DF0534
RAILROAD MEDICARE
IL
Enumeration date
10/06/2006
Last updated
07/16/2009
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