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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1295809614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LICKING MEMORIAL PROFESSIONAL CORP.

Provider Business Mailing Address
First Line	:	1 HEALTHY PL
Second Line	:	SUITE 105
City	:	PATASKALA
State	:	OH
Zip	:	43062-7067
Country	:	US
Telephone Number	:	740-348-1930
Fax Number	:	740-348-1931

Provider Business Practice Location Address
First Line	:	1 HEALTHY PL
Second Line	:	SUITE 105
City	:	PATASKALA
State	:	OH
Zip	:	43062-7067
Country	:	US
Telephone Number	:	740-348-1930
Fax Number	:	740-348-1931

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	ROBERT MONTAGNESE
Credential	:
Telephone Number	:	740-348-4000

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	08/22/2020

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Directions to “LICKING MEMORIAL PROFESSIONAL CORP. ” Practice Location

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