Provider Demographics
NPI:1326068768
Name:LICKING MEMORIAL PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORP.
Other - Org Name:LICKING MEMORIAL PULMONOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP 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:740-348-4027
Mailing Address - Street 1:1320 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1822
Mailing Address - Country:US
Mailing Address - Phone:740-348-1805
Mailing Address - Fax:740-348-1806
Practice Address - Street 1:1320 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1822
Practice Address - Country:US
Practice Address - Phone:740-348-1805
Practice Address - Fax:740-348-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========-16OtherBWC
OH=========-16OtherBWC