NPIMap

Organization Active NPI

Licking Memorial Professional Corp.

Doing business as Licking Memorial Geriatric Medicine at Autumn

  • Geriatric Medicine (Family Medicine) Physician
  • Newark, OH
National Provider Identifier
1235311358
Registry record updated Nov 30, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Medicine (Family Medicine) PhysicianTaxonomy code 207QG0300X
Legal business name
LICKING MEMORIAL PROFESSIONAL CORP.
Doing business as
Licking Memorial Geriatric Medicine at Autumn
Practice address
17 Forry St
Newark, OH 43055-4004
Phone
(740) 348-7935
Fax
(740) 348-7936
NPI assigned
Nov 30, 2007
Last updated
Nov 30, 2007By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 30, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Thomas N. Poulson
Title
Cfo
Phone
(740) 348-4110

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Geriatric Medicine (Family Medicine) Physician 207QG0300X NU Primary

Addresses

Primary practice location

17 Forry St
Newark, OH 43055-4004

Mailing address

17 Forry St
Newark, OH 43055-4004
Phone (740) 348-7935

Other names 1

  • Licking Memorial Geriatric Medicine at Autumn Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Licking Memorial Pumonology9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1196380800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1196380800000",
    "number": "1235311358",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17 FORRY ST",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430554004",
            "telephone_number": "740-348-7935",
            "fax_number": "740-348-7936"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17 FORRY ST",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430554004",
            "telephone_number": "740-348-7935",
            "fax_number": "740-348-7936"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LICKING MEMORIAL PROFESSIONAL CORP.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-11-30",
        "last_updated": "2007-11-30",
        "status": "A",
        "authorized_official_last_name": "POULSON",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_middle_name": "N.",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "740-348-4110"
    },
    "taxonomies": [
        {
            "code": "207QG0300X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Geriatric Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Licking Memorial Geriatric Medicine at Autumn",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Newark, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 30, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.