Provider Demographics
NPI:1831381797
Name:LICKING MEMORIAL PROFESSIONAL CORP
Entity type:Organization
Organization Name:LICKING MEMORIAL PROFESSIONAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:740-348-4819
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:740-348-7960
Mailing Address - Fax:740-348-7961
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:740-348-7960
Practice Address - Fax:740-348-7961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty