MEDICARE: MARY JOYCE RICO MD

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	207N00000X	Dermatology Physician	13878	NC
2	207N00000X	Dermatology Physician	30465	NC
3	207N00000X	Dermatology Physician	LL-909	FL

General Provider Information

NPI Number	:	1245338342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JOYCE RICO MD

Provider Business Mailing Address
First Line	:	1432 NE 105TH ST
Second Line	:
City	:	MIAMI SHORES
State	:	FL
Zip	:	33138-2114
Country	:	US
Telephone Number	:	224-216-7749
Fax Number	:	847-835-9946

Provider Business Practice Location Address
First Line	:	1432 NE 105TH ST
Second Line	:
City	:	MIAMI SHORES
State	:	FL
Zip	:	33138-2114
Country	:	US
Telephone Number	:	224-216-7749
Fax Number	:	847-835-9946

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	02/18/2022

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