MEDICARE: DR. GARY MELVIN LICKLIDER M.D.

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	208800000X	Urology Physician	18083	WI

General Provider Information

NPI Number	:	1588998538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY MELVIN LICKLIDER M.D.

Provider Business Mailing Address
First Line	:	5002 PRAIRIE ROSE CT
Second Line	:
City	:	MIDDLETON
State	:	WI
Zip	:	53562-2385
Country	:	US
Telephone Number	:	608-836-9623
Fax Number	:

Provider Business Practice Location Address
First Line	:	5002 PRAIRIE ROSE CT
Second Line	:
City	:	MIDDLETON
State	:	WI
Zip	:	53562-2385
Country	:	US
Telephone Number	:	608-836-9623
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2009
Last Update Date	:	09/23/2009

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