Provider Demographics
NPI:1104939420
Name:LICKERT, CASSANDRA ADAMS (MD)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:ADAMS
Last Name:LICKERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:MARCIA
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:20110 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1030
Mailing Address - Country:US
Mailing Address - Phone:708-747-7960
Mailing Address - Fax:708-503-3993
Practice Address - Street 1:9550 W 167TH ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5561
Practice Address - Country:US
Practice Address - Phone:708-873-4500
Practice Address - Fax:708-873-4505
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202506Medicare ID - Type Unspecified
H43876Medicare UPIN
IL795780Medicare ID - Type Unspecified