Provider Demographics
NPI:1336169770
Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Other - Org Name:LICKING MEMORIAL FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONTAGNESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-348-4000
Mailing Address - Street 1:1272 W MAIN ST
Mailing Address - Street 2:BLDG. 1
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2004
Mailing Address - Country:US
Mailing Address - Phone:740-348-1702
Mailing Address - Fax:740-348-1703
Practice Address - Street 1:1272 W MAIN ST
Practice Address - Street 2:BLDG. 1
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2004
Practice Address - Country:US
Practice Address - Phone:740-348-1702
Practice Address - Fax:740-348-1703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2140169Medicaid
OH2140169Medicaid
OHLI9301872Medicare ID - Type Unspecified