Provider Demographics
NPI:1073822938
Name:LICKING MEMORIAL PROFESSIONAL CORP
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORP
Other - Org Name:LICKING MEMORIAL ENDOCRINOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-348-4518
Mailing Address - Street 1:1272 W MAIN ST
Mailing Address - Street 2:BLDG 2 STE 3
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2004
Mailing Address - Country:US
Mailing Address - Phone:740-348-7950
Mailing Address - Fax:740-348-7951
Practice Address - Street 1:1272 W MAIN ST
Practice Address - Street 2:BLDG 2 STE 3
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2004
Practice Address - Country:US
Practice Address - Phone:740-348-7950
Practice Address - Fax:740-348-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty