Basic Information
Provider Information | |||||||||
NPI: | 1235311358 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LICKING MEMORIAL PROFESSIONAL CORP. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LICKING MEMORIAL GERIATRIC MEDICINE AT AUTUMN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17 FORRY ST | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | OH | ||||||||
PostalCode: | 430554004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403487935 | ||||||||
FaxNumber: | 7403487936 | ||||||||
Practice Location | |||||||||
Address1: | 17 FORRY ST | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | OH | ||||||||
PostalCode: | 430554004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403487935 | ||||||||
FaxNumber: | 7403487936 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2007 | ||||||||
LastUpdateDate: | 11/30/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POULSON | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | N. | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7403484110 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.