Basic Information
| Provider Information | |||||||||
| NPI: | 1649290073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LICKING MEMORIAL PROFESSIONAL CORP. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LICKING MEMORIAL GERIATRIC MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 MCMILLEN DR | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403487935 | ||||||||
| FaxNumber: | 7403487936 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MCMILLEN DR | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403487935 | ||||||||
| FaxNumber: | 7403487936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONTAGNESE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE V.P. | ||||||||
| AuthorizedOfficialTelephone: | 7403484000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.