Healthcare Provider Details

I. General information

NPI: 1598945818
Provider Name (Legal Business Name): LICKING MEMORIAL PROFESSIONAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 S 30TH ST
NEWARK OH
43056-1244
US

IV. Provider business mailing address

717 S 30TH ST
NEWARK OH
43056-1244
US

V. Phone/Fax

Practice location:
  • Phone: 740-348-7935
  • Fax: 740-348-7936
Mailing address:
  • Phone: 740-348-7935
  • Fax: 740-348-7936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS N. POULSON
Title or Position: CFO
Credential:
Phone: 740-348-4110