NPIMap

Organization Active NPI

Licking Memorial Professional Corporation

Doing business as Licking Memorial Dermatology

  • Dermatology Physician
  • Newark, OH
National Provider Identifier
1295775435
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
LICKING MEMORIAL PROFESSIONAL CORPORATION
Doing business as
Licking Memorial Dermatology
Practice address
36 McMillen Dr
Newark, OH 43055-3666
Phone
(740) 348-1755
Fax
(740) 348-1756
NPI assigned
Jun 7, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Robert A. Montagnese
Title
Executive Ice President
Phone
(740) 348-4000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

36 McMillen Dr
Newark, OH 43055-3666

Mailing address

36 McMillen Dr
Newark, OH 43055-3666
Phone (740) 348-1755

Other identifiers 1

IdentifierTypeStateIssuer
2527975MedicaidOH

Other names 1

  • Licking Memorial Dermatology Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031203000131 OH Part B Supplier - Clinic/Group Practice 6204740731 Receives reassigned benefits from 282 practitioners
45 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Newark, OH; Pataskala, OH; Utica, OH; Heath, OH; Hebron, OH; Johnstown, OH; Granville, OH

Other NPIs on the same Medicare enrollment 45

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 45

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1149638400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1295775435",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "36 MCMILLEN DR",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430553666",
            "telephone_number": "740-348-1755",
            "fax_number": "740-348-1756"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "36 MCMILLEN DR",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430553666",
            "telephone_number": "740-348-1755",
            "fax_number": "740-348-1756"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LICKING MEMORIAL PROFESSIONAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-07",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "MONTAGNESE",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "EXECUTIVE ICE PRESIDENT",
        "authorized_official_telephone_number": "740-348-4000"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2527975",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Licking Memorial Dermatology",
            "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 Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.