LICKING MEMORIAL PROFESSIONAL CORPORATION (NPI# 1336169770) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1336169770 |
| Entity Type | Organization |
| Organization Name | LICKING MEMORIAL PROFESSIONAL CORPORATION |
| Other Organization Name | LICKING MEMORIAL FAMILY PRACTICE |
| Practice Address |
1272 W Main St Bldg. 1 Newark OH 43055-2004 |
| Practice Telephone | 7403481702 |
| Practice Fax Number | 7403481703 |
| Mailing Telephone | 7403481702 |
| Mailing Fax Number | 7403481703 |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2020-08-22 |
| Authorized Official Name | ROBERT A. MONTAGNESE (EXECUTIVE VICE PRESIDENT) |
| Authorized Official Telephone | 7403484000 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 207Q00000X | Family Medicine | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| OH | 2140169 | 05 |
| Other Name | Type Code |
|---|---|
| Licking Memorial Family Practice | Doing Business As Name - Organization |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1053758631 | Licking Memorial Professional Corporation | Obstetrics & Gynecology | 270 Goosepond Road, Ste 102, Newark, OH 43055 | 2013-05-23 |
| 1740623628 | Licking Memorial Professional Corporation | Internal Medicine | 1272 West Main Street Bldg 2, Ste 4, Newark, OH 43055 | 2013-04-10 |
| 1457625758 | Licking Memorial Professional Corporation | Dermatology | 1272 West Main Street Bldg 2 Ste. 2, Newark, OH 43055 | 2012-03-05 |
| 1093955932 | Licking Memorial Professional Corporation | Surgery | 1 Healthy Pl Ste 202, Pataskala, OH 43062-7067 | 2009-03-05 |
| 1083646442 | Licking Memorial Professional Corporation | Otolaryngology | 88 Mcmillen Dr, Newark, OH 43055-5814 | 2006-07-07 |
| 1326436510 | Licking Memorial Professional Corporation | Durable Medical Equipment & Medical Supplies | 1717 W Main St, Suite 201, Newark, OH 43055-1347 | 2014-12-23 |
| 1700291416 | Licking Memorial Professional Corporation | Dermatology | 1 Healthy Pl, Suite 205, Pataskala, OH 43062-7067 | 2014-06-23 |
| 1962684084 | Licking Memorial Professional Corporation | Family Medicine | 75 Mcmillen Dr, Newark, OH 43055-1808 | 2007-11-30 |
| 1952581274 | Licking Memorial Professional Corporation | Family Medicine | 151 Price Rd, Newark, OH 43055-3317 | 2007-11-05 |
| 1578755435 | Licking Memorial Professional Corporation | Psychiatry & Neurology | 1272 West Main Street, Bldg 2, Newark, OH 43055-2004 | 2007-08-15 |
| Street Address |
1272 W MAIN ST BLDG. 1 |
| City | NEWARK |
| State | OH |
| Zip Code | 43055-2004 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1043218068 | Carl Waggoner | Family Medicine | 1272 W Main St, Bldg. 5, Newark, OH 43055-2034 | 2005-07-13 |
| 1073822938 | Licking Memorial Professional Corp | Internal Medicine | 1272 W Main St, Bldg 2 Ste 3, Newark, OH 43055-2004 | 2010-09-27 |
| 1134430887 | Read's Pharmacy LLC | Pharmacy | 1272 W Main St, Newark, OH 43055-2004 | 2010-06-28 |
| 1396905584 | Christopher Matthew Forbush | Family Medicine | 1272 W Main St, Suite 503, Newark, OH 43055 | 2008-06-11 |
| 1932389335 | Newark Orthopaedics,inc. | Orthopaedic Surgery | 1272 W Main St, Building 2, Newark, OH 43055-2004 | 2007-11-14 |
| 1831381706 | Licking Memorial Professional Corporation | Surgery | 1272 W Main St, Bldg. 2, Newark, OH 43055-2004 | 2007-08-15 |
| 1871654681 | Paul Norman Montalto | Family Medicine | 1272 W Main St, Suite 2, Newark, OH 43055-2004 | 2006-12-13 |
| 1063580199 | Catherine Chiodo | Podiatrist | 1272 W Main St, Building #4, Newark, OH 43055-2004 | 2006-11-30 |
| 1063518926 | Michael Bradshaw Vitt | Dentist | 1272 W Main St, Bldg 3, Newark, OH 43055-2004 | 2006-09-16 |
| 1366461386 | Licking Memorial Professional Corp. | Surgery | 1272 W Main St, Bldg. 3, Newark, OH 43055-2004 | 2006-07-19 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1770125585 | Jessica Danielle Dunkle | Case Manager/Care Coordinator | 15 N 3rd Street Suite 300, Newark, OH 43055 | 2019-10-14 |
| 1558910331 | Diana Cleland | Home Health Aide | 25 Western Rd, Apartment A, Newark, OH 43055 | 2019-09-05 |
| 1912424789 | Sandra Lou Fraley | Community/Behavioral Health | 15 North 3rd Street, Suite 300, Newark, OH 43055 | 2017-08-23 |
| 1215450911 | Caitlyn Thella Smith Elkins | Social Worker | 15 N. 3rd St., Newark, OH 43055 | 2017-07-25 |
| 1992227888 | Sierra Elizabeth Donley | Student in an Organized Health Care Education/Training Program | 140 W Church St, Newark, OH 43055 | 2017-07-12 |
| 1386170587 | Patricia Louise Fischer | Pharmacist | 1155 North 21rst Street, Newark, OH 43055 | 2017-05-08 |
| 1689120958 | Bebout Services, LLC | Home Health | 1325 Dayton Road Ne, Newark, OH 43055 | 2016-08-28 |
| 1750834594 | Laura Smith | Registered Nurse | 1445 West Main Street, Suite B, Newark, OH 43055 | 2016-07-28 |
| 1164807277 | Frank Kobe | Psychologist | 116 N. 21st Street, Newark, OH 43055 | 2015-07-30 |
| 1770975898 | Gentle Foot Care, Inc | Podiatrist | 1271 W Main Street, Bldg 1, Newark, OH 43055 | 2015-02-26 |
| Find all providers in zip 43055 | ||||
| Taxonomy Code | 207Q00000X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Family Medicine |
| Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. |
| Notes: Source: American Board of Family Medicine [1/1/2007: changed title; 7/1/2007: added definition, added source; 7/1/2017: modified definition] - Note: The American Osteopathic Board of Family Physicians certification includes extensive use of Osteopathic Manipulative Treatment (OMT), which integrates the biological, clinical, and behavioral sciences. - Additional Resources: American Board of Family Medicine, www.theabfm.org. American Osteopathic Board of Family Physicians, www.osteopathic.org/certification - Board certification for Medical Doctors (MDs) is provided by the American Board of Family Medicine. Board certification for Doctors of Osteopathy (DOs) is provided by the American Osteopathic Board of Family Physicians or the American Board of Family Medicine. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1104461763 | Ginna Elizabeth Keil | Family Medicine | 16 Polly Drummond Shpg Ctr Ste 2, Newark, DE 19711-4861 | 2019-11-07 |
| 1386290609 | Corisa Mccloud | Family Medicine | 1025 Lawnview Ave, Newark, OH 43055-2611 | 2019-08-13 |
| 1811408172 | Bmg Newark LLC | Family Medicine | 794 Mount Prospect Ave Fl 2, Newark, NJ 07104-3221 | 2017-10-13 |
| 1982093852 | Physicians Care of Newark, Inc | Family Medicine | 68 Omega Dr, Suite D, Newark, DE 19713-2063 | 2015-01-15 |
| 1316365646 | Emmanuelle Ruocco | Family Medicine | 90 Bergen St Ste 300, Newark, NJ 07103-2425 | 2014-04-03 |
| 1366886368 | Amanda J Taylor | Family Medicine | 4755 Ogletown Stanton Rd Ste 6e34, Newark, DE 19718 | 2013-04-20 |
| 1033477104 | Ironbound Family Medicine LLC | Family Medicine | 154 Van Buren St, 1st Floor, Newark, NJ 07105-2984 | 2012-04-26 |
| 1164790002 | St. Francis Hospital, Inc | Family Medicine | 1220 Capitol Trl, Newark, DE 19711-3924 | 2011-12-07 |
| 1255624896 | Carlos Alfonso Sanchez | Family Medicine | 617 Broad St, Newark, NJ 07102-4403 | 2011-05-16 |
| 1306072947 | Glenda Albizu | Family Medicine | 300 Biddle Ave Ste 200, Newark, DE 19702 | 2009-06-10 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.