Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | ME 78360 | FL |
Y | 208600000X | Surgeon | ME 78360 | FL |
N | 2086S0102X | Surgical Critical Care | ME78360 | FL |
N | 2086S0127X | Trauma Surgeon | ME78360 | FL |
N | 2086S0129X | Vascular Surgeon | ME78360 | FL |
N | 2086X0206X | Surgical Oncologist | ME78360 | FL |
NPI | 1386746063 |
---|---|
Provider Name | Dr. Ian A Concilio |
First Address | Port St Lucie, FL 34985-7665 |
Second Address | Port St Lucie, FL 34952-3360 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2006 |
Last Update Date | 27/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H02337 | (02) |