MEDICARE: LICUDINE & LICUDINE MD SC

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	208600000X	Surgery Physician	036046217	IL
2	207Q00000X	Family Medicine Physician	036051696	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538245832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LICUDINE & LICUDINE MD SC

Provider Business Mailing Address
First Line	:	7049 N KILPATRICK AVE
Second Line	:
City	:	LINCOLNWOOD
State	:	IL
Zip	:	60712-2128
Country	:	US
Telephone Number	:	847-677-7264
Fax Number	:

Provider Business Practice Location Address
First Line	:	4758 W WASHINGTON BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-3619
Country	:	US
Telephone Number	:	773-379-4348
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	DR. NORMITA M LICUDINE
Credential	:	MD
Telephone Number	:	773-379-4348

Provider Enumeration Date	:	10/29/2006
Last Update Date	:	04/13/2010

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Directions to “LICUDINE & LICUDINE MD SC ” Practice Location

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