NPIMap

Organization Active NPI

Licking Memorial Professional Corp.

Doing business as Licking Memorial Family Practice Heath

  • Family Medicine Physician
  • Heath, OH
National Provider Identifier
1487688545
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
LICKING MEMORIAL PROFESSIONAL CORP.
Doing business as
Licking Memorial Family Practice Heath
Practice address
687 Hopewell Dr
Suite2
Heath, OH 43056-1579
Phone
(740) 348-7915
Fax
(740) 348-7916
NPI assigned
Jul 11, 2006
Last updated
Aug 22, 2020By the provider in NPPES
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 V.P.
Phone
(740) 348-4000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

687 Hopewell Dr
Suite2
Heath, OH 43056-1579

Mailing address

687 Hopewell Dr
Suite2
Heath, OH 43056-1579
Phone (740) 348-7915

Other names 1

  • Licking Memorial Family Practice Heath 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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
36D1036911Licking Memorial Family Practice Heath687 Hopewell Dr Building 2, Heath, OH 43056Certificate of waiverMar 21, 2028

National Provider Directory

National Provider Directory

Locations

687 Hopewell Dr
Ste 2
Heath, OH 43056
Phone (740) 348-7915

NPI Registry JSON

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

{
    "created_epoch": "1152576000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1487688545",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "687 HOPEWELL DR",
            "address_2": "SUITE2",
            "city": "HEATH",
            "state": "OH",
            "postal_code": "430561579",
            "telephone_number": "740-348-7915",
            "fax_number": "740-348-7916"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "687 HOPEWELL DR",
            "address_2": "SUITE2",
            "city": "HEATH",
            "state": "OH",
            "postal_code": "430561579",
            "telephone_number": "740-348-7915",
            "fax_number": "740-348-7916"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LICKING MEMORIAL PROFESSIONAL CORP.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-11",
        "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 V.P.",
        "authorized_official_telephone_number": "740-348-4000"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Licking Memorial Family Practice Heath",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Heath, 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.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.