Individual
SAMUEL D. LICCIARDO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
55 LAKE AVE N, DEPARTMENT OF EMERGENCY MEDICINE, WORCESTER, MA 01655-0002
(508) 421-1400
(508) 421-1490
Mailing address
PO BOX 415348, BOSTON, MA 02241-5348
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
253748
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110095480A
—
MA
Enumeration date
06/03/2010
Last updated
10/28/2013
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