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General NPI Number Information
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NPI Number | 1093036659
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Entity Type | Organization
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Legal Business Name | SERRIE C. LICO MD, CARDIOVASCULAR & THORACIC SURGERY PC
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Dates
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Enumeration Date | 06/17/2010
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Last Update Date | 01/22/2013
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Provider Practice Location Address
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Address Line | 515 ABBOTT RD SUITE 101
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City | BUFFALO
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State | NY
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Zip | 14220-1700
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Country | US
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Telephone | 716-821-7714
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Fax | 716-821-7716
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Provider Business Mailing Address
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Address Line | PO BOX 24
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City | ORCHARD PARK
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State | NY
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Zip | 14127-0024
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Country | US
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Telephone | 716-821-7714
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Fax | 716-821-7716
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SERRIE C. LICO
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Credential | M.D.
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Telephone | 716-821-7714
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | 184556-1
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License Number State | NY
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