Healthcare Provider Details

I. General information

NPI: 1831381706
Provider Name (Legal Business Name): LICKING MEMORIAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 W MAIN ST BLDG. 2
NEWARK OH
43055-2004
US

IV. Provider business mailing address

1272 W MAIN ST BLDG. 2
NEWARK OH
43055-2004
US

V. Phone/Fax

Practice location:
  • Phone: 740-348-7955
  • Fax: 740-348-7956
Mailing address:
  • Phone: 740-348-7955
  • Fax: 740-348-7956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RENEE SPRING-IVES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 740-348-4027