{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "SERRIE C. LICO MD, CARDIOVASCULAR & THORACIC SURGERY PC",
"LastName": null,
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"FirstLineMailingAddress": "PO BOX 24",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ORCHARD PARK",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "14127-0024",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "716-821-7714",
"MailingAddressFaxNumber": "716-821-7716",
"FirstLinePracticeLocationAddress": "515 ABBOTT RD",
"SecondLinePracticeLocationAddress": "SUITE 101",
"PracticeLocationAddressCityName": "BUFFALO",
"PracticeLocationAddressStateName": "NY",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "716-821-7714",
"PracticeLocationAddressFaxNumber": "716-821-7716",
"EnumerationDate": "06/17/2010",
"LastUpdateDate": "01/22/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LICO",
"AuthorizedOfficialFirstName": "SERRIE",
"AuthorizedOfficialMiddleName": "C.",
"AuthorizedOfficialTitle": "PRESIDENT",
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"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "716-821-7714",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "208G00000X",
"TaxonomyName": "Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician",
"LicenseNumber": "184556-1",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}