Provider Demographics
NPI:1093955932
Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Other - Org Name:LICKING MEMORIAL PATASKALA SPECIALTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP REVENUE CYCLE & INTERIM VP FINAN
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-348-4027
Mailing Address - Street 1:1 HEALTHY PL STE 202
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-7067
Mailing Address - Country:US
Mailing Address - Phone:740-348-1935
Mailing Address - Fax:740-348-1936
Practice Address - Street 1:1 HEALTHY PL STE 202
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-7067
Practice Address - Country:US
Practice Address - Phone:740-348-1935
Practice Address - Fax:740-348-1936
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LICKING MEMORIAL PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-05
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008308208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty