Healthcare Provider Details

I. General information

NPI: 1851325526
Provider Name (Legal Business Name): LICKING MEMORIAL PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HEALTHY PL SUITE 101
PATASKALA OH
43062-7067
US

IV. Provider business mailing address

1 HEALTHY PL SUITE 101
PATASKALA OH
43062-7067
US

V. Phone/Fax

Practice location:
  • Phone: 740-348-1900
  • Fax: 740-348-1901
Mailing address:
  • Phone: 740-348-1900
  • Fax: 740-348-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT A. MONTAGNESE
Title or Position: EXECUTIVE V.P.
Credential:
Phone: 740-348-4000