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	:	1851325526
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 101
City	:	PATASKALA
State	:	OH
Zip	:	43062-7067
Country	:	US
Telephone Number	:	740-348-1900
Fax Number	:	740-348-1901

Provider Business Practice Location Address
First Line	:	1 HEALTHY PL
Second Line	:	SUITE 101
City	:	PATASKALA
State	:	OH
Zip	:	43062-7067
Country	:	US
Telephone Number	:	740-348-1900
Fax Number	:	740-348-1901

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

1 HEALTHY PL , SUITE 101
PATASKALA, OH
43062-7067

Practice Phone: 220-564-1900
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Practice Location Address:

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1235159674 — LICKING MEMORIAL PROFESSIONAL CORP.
Practice Location Address:

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43062-7067

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Practice Location Address:

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1952479115 — CONNIE S JENKINS MD
Practice Location Address:

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Directions to “LICKING MEMORIAL PROFESSIONAL CORP ” Practice Location

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