Provider Demographics
NPI:1700291416
Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Other - Org Name:LICKING MEMORIAL DERMATOLOGY PATASKALA
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:740-348-4518
Mailing Address - Street 1:1 HEALTHY PL
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-7067
Mailing Address - Country:US
Mailing Address - Phone:740-348-1930
Mailing Address - Fax:740-348-1931
Practice Address - Street 1:1 HEALTHY PL
Practice Address - Street 2:SUITE 205
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-7067
Practice Address - Country:US
Practice Address - Phone:740-348-1930
Practice Address - Fax:740-348-1931
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LICKING MEMORIAL PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty