Provider Demographics
NPI:1144240581
Name:LICKING MEMORIAL PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORP.
Other - Org Name:LICKING MEMORIAL PEDIATRICS PATASKALA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCIAL SERVICE
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:740-348-4000
Mailing Address - Street 1:1 HEALTHY PL
Mailing Address - Street 2:STE 203
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062
Mailing Address - Country:US
Mailing Address - Phone:740-348-1925
Mailing Address - Fax:740-348-1926
Practice Address - Street 1:1 HEALTHY PL
Practice Address - Street 2:STE 203
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062
Practice Address - Country:US
Practice Address - Phone:740-348-1925
Practice Address - Fax:740-348-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2596767Medicaid
OH2596767Medicaid