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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