Provider Demographics
NPI:1740623628
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:VP FINANCIAL SERVICE
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 1:1272 WEST MAIN STREET BLDG 2
Mailing Address - Street 2:STE 4
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:740-348-7975
Mailing Address - Fax:740-348-7976
Practice Address - Street 1:1272 WEST MAIN STREET BLDG 2
Practice Address - Street 2:STE 4
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055
Practice Address - Country:US
Practice Address - Phone:740-348-7975
Practice Address - Fax:740-348-7976
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LICKING MEMORIAL PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty