Provider Demographics
NPI:1740472604
Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDNATOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPRING-IVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-348-4027
Mailing Address - Street 1:270 GOOSEPOND RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-3104
Mailing Address - Country:US
Mailing Address - Phone:740-348-7945
Mailing Address - Fax:740-348-7946
Practice Address - Street 1:270 GOOSEPOND RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-3104
Practice Address - Country:US
Practice Address - Phone:740-348-7945
Practice Address - Fax:740-348-7946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty