Healthcare Provider Details

I. General information

NPI: 1154652576
Provider Name (Legal Business Name): MARINA V KULICK MD PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1744 S PINELLAS AVE
TARPON SPRINGS FL
34689-1939
US

IV. Provider business mailing address

1744 S PINELLAS AVE
TARPON SPRINGS FL
34689-1939
US

V. Phone/Fax

Practice location:
  • Phone: 727-940-3478
  • Fax: 727-940-3480
Mailing address:
  • Phone: 727-940-3478
  • Fax: 727-940-3480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberME103499
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME103499
License Number StateFL

VIII. Authorized Official

Name: MARINA V KULICK
Title or Position: DIRECTOR/PRESIDNT
Credential: M.D.
Phone: 727-940-3478