Provider Demographics
NPI:1154496503
Name:LICKING MEMORIAL PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORP.
Other - Org Name:LICKING MEMORIAL PHYSICIAN WOUND SERVICES
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:740-348-4518
Mailing Address - Street 1:2000 TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:740-348-1993
Mailing Address - Fax:740-348-1994
Practice Address - Street 1:2000 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055
Practice Address - Country:US
Practice Address - Phone:740-348-1993
Practice Address - Fax:740-348-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty