Cicero Medical Clinica San Lazaro LLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

CICERO MEDICAL CLINICA SAN LAZARO LLC

Practice address

5712 W 35TH St
Cicero, IL 60804-4222

Phone

(708) 656-5485

Fax

(708) 656-5657

NPI assigned

Oct 6, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Gerard Licea, MBA

Title

Registered Agent

Phone

(708) 656-5485

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Rosaura Licea, MD

  • Family Medicine Physician
  • Cicero, IL
  • NPI 1548299225

  IL

  Medicare reassignment
• Tiffany Hilliard

  • Family Nurse Practitioner
  • Cicero, IL
  • NPI 1386190783
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160092800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1247702400000",
    "number": "1295822716",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5712 W 35TH ST",
            "city": "CICERO",
            "state": "IL",
            "postal_code": "608044222",
            "telephone_number": "708-656-5485",
            "fax_number": "708-656-5657"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5712 W 35TH ST",
            "city": "CICERO",
            "state": "IL",
            "postal_code": "608044222",
            "telephone_number": "708-656-5485",
            "fax_number": "708-656-5657"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CICERO MEDICAL CLINICA SAN LAZARO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-06",
        "last_updated": "2009-07-16",
        "status": "A",
        "authorized_official_last_name": "LICEA",
        "authorized_official_first_name": "GERARD",
        "authorized_official_title_or_position": "REGISTERED AGENT",
        "authorized_official_telephone_number": "708-656-5485",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MBA"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "DF0534",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTHSPRING",
            "identifier": "0179982",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "1636532",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Chicago Treatment & Counseling Center #3
• Chicago Treatment & Counseling Center #4
• Cicero Chiropractic Care PLLC
• Cicero Dental Center LLC
• Cicero District 99
• Cicero Pediatrics
• Wayne Richard Cichowicz, D.N., L.D.N.
• City View Multicare Center LLC
• Xiomara D. Clanton, LCSW
• Gary J. Clyman, L.AC.

• All providers in Cicero, IL
• Family Medicine Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.