MEDICARE: R PAUL LICCINI MD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DG1282	OTHER	FL	RAIL ROAD MEDICARE

General Provider Information

NPI Number	:	1174588594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R PAUL LICCINI MD LLC

Provider Business Mailing Address
First Line	:	12645 NEW BRITTANY BLVD
Second Line	:	BLDG 15
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3631
Country	:	US
Telephone Number	:	239-936-2220
Fax Number	:	239-936-2444

Provider Business Practice Location Address
First Line	:	12645 NEW BRITTANY BLVD
Second Line	:	BLDG 15
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3631
Country	:	US
Telephone Number	:	239-936-2220
Fax Number	:	239-936-2444

Authorized Official
Title or Position	:	OWNER
Name	:	DR. R. PAUL LICCINI
Credential	:	M.D.
Telephone Number	:	239-936-2220

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	07/29/2010

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Directions to “R PAUL LICCINI MD LLC ” Practice Location

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