| Cicero Medical Clinica San Lazaro Llc | |
|
5712 W 35th St Cicero IL 60804-4222 | |
| (708) 656-5485 | |
| (708) 656-5657 |
| Full Name | Cicero Medical Clinica San Lazaro Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 5712 W 35th St, Cicero, Illinois |
| Authorized Official Name and Position | Gerard Licea (REGISTERED AGENT) |
| Authorized Official Contact | 7086565485 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Cicero Medical Clinica San Lazaro Llc 5712 W 35th St Cicero IL 60804-4222 Ph: (708) 656-5485 | Cicero Medical Clinica San Lazaro Llc 5712 W 35th St Cicero IL 60804-4222 Ph: (708) 656-5485 |
| NPI Number | 1295822716 |
|---|---|
| Provider Enumeration Date | 10/06/2006 |
| Last Update Date | 07/16/2009 |
| Medicare PECOS PAC ID | 0143226324 |
|---|---|
| Medicare Enrollment ID | O20061011000332 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1295822716 | NPI | - | NPPES |
| DF0534 | Other | IL | RAILROAD MEDICARE |
| 0179982 | Other | IL | HEALTHSPRING |
| 1636532 | Other | IL | BLUE CROSS BLUE SHIELD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Rosaura Licea |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1548299225 PECOS PAC ID: 4789580721 Enrollment ID: I20040105000094 |
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