Provider Demographics
NPI:1598945818
Name:LICKING MEMORIAL PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORP.
Other - Org Name:LICKING MEMORIAL GERIATRIC MEDICINE AT HNC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:N
Authorized Official - Last Name:POULSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-348-4110
Mailing Address - Street 1:717 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43056-1244
Mailing Address - Country:US
Mailing Address - Phone:740-348-7935
Mailing Address - Fax:740-348-7936
Practice Address - Street 1:717 S 30TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43056-1244
Practice Address - Country:US
Practice Address - Phone:740-348-7935
Practice Address - Fax:740-348-7936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty