MEDICARE: MCL PRIMARY CARE, 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	207Q00000X	Family Medicine Physician	OS014106	PA

General Provider Information

NPI Number	:	1114251816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCL PRIMARY CARE, LLC.

Provider Business Mailing Address
First Line	:	882 JACKSONVILLE RD
Second Line	:	SUITE 204
City	:	IVYLAND
State	:	PA
Zip	:	18974-4836
Country	:	US
Telephone Number	:	215-957-1100
Fax Number	:	215-957-1111

Provider Business Practice Location Address
First Line	:	882 JACKSONVILLE RD
Second Line	:	SUITE 204
City	:	IVYLAND
State	:	PA
Zip	:	18974-4836
Country	:	US
Telephone Number	:	215-957-1100
Fax Number	:	215-957-1111

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. MICHAEL C. LUCIANO
Credential	:	D.O.
Telephone Number	:	215-957-1100

Provider Enumeration Date	:	09/28/2009
Last Update Date	:	11/16/2009

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