MEDICARE: LICKING MEMORIAL PROFESSIONAL CORP.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1689690661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LICKING MEMORIAL PROFESSIONAL CORP.

Provider Business Mailing Address
First Line	:	96 INTEGRITY DRIVE
Second Line	:
City	:	HEBRON
State	:	OH
Zip	:	43025
Country	:	US
Telephone Number	:	740-348-7930
Fax Number	:	740-348-7931

Provider Business Practice Location Address
First Line	:	96 INTEGRITY DRIVE
Second Line	:	H.
City	:	HEBRON
State	:	OH
Zip	:	43025
Country	:	US
Telephone Number	:	740-348-7930
Fax Number	:	740-348-7931

Authorized Official
Title or Position	:	EXECUTIVE V.P.
Name	:	ROBERT A. MONTAGNESE
Credential	:
Telephone Number	:	740-348-4000

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	08/22/2020

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