Provider Demographics
NPI:1720163637
Name:LICKING MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:LICKING MEMORIAL HOSPITAL
Other - Org Name:LICKING MEMORIAL HOSPITAL HOMECARE
Other - Org Type:Other Name
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 1:1865 TAMARACK RD STE B
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2316
Mailing Address - Country:US
Mailing Address - Phone:740-348-1860
Mailing Address - Fax:740-348-1861
Practice Address - Street 1:1865 TAMARACK RD STE B
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2316
Practice Address - Country:US
Practice Address - Phone:740-348-1860
Practice Address - Fax:740-348-1861
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LICKING MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0869092Medicaid
OH0869092Medicaid