Basic Information
| Provider Information | |||||||||
| NPI: | 1497937510 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LICKING MEMORIAL PROFESSIONAL CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LICKING MEMORIAL GERIATRIC MEDICINE AT FLINT RIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403487935 | ||||||||
| FaxNumber: | 7403487936 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403487935 | ||||||||
| FaxNumber: | 7403487936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2007 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | POULSON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7403484110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.