Provider Demographics
NPI:1457625758
Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Other - Org Name:LICKING MEMORIAL DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF 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 1:1272 WEST MAIN STREET BLDG 2 STE. 2
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:740-348-1760
Mailing Address - Fax:740-348-1761
Practice Address - Street 1:1272 WEST MAIN STREET BLDG 2 STE. 2
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055
Practice Address - Country:US
Practice Address - Phone:740-348-1760
Practice Address - Fax:740-348-1761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty