Provider Demographics
NPI:1083634414
Name:LICKING MEMORIAL PROFESSIONAL CORP
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORP
Other - Org Name:LICKING MEMORIAL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE V.P.
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONTAGNESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-348-4000
Mailing Address - Street 1:1865 TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2305
Mailing Address - Country:US
Mailing Address - Phone:740-348-4940
Mailing Address - Fax:740-348-4948
Practice Address - Street 1:1865 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2305
Practice Address - Country:US
Practice Address - Phone:740-348-4940
Practice Address - Fax:740-348-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0617194Medicaid
OH0617194Medicaid