NPIMap

Organization Active NPI

Licking Memorial Professional Corp.

Doing business as Licking Memorial Family Practice Hebron

  • Family Medicine Physician
  • Hebron, OH
National Provider Identifier
1689690661
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 Hebron
Practice address
96 Integrity Drive
H.
Hebron, OH 43025
Phone
(740) 348-7930
Fax
(740) 348-7931
NPI assigned
Jul 14, 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

96 Integrity Drive
H.
Hebron, OH 43025

Mailing address

96 Integrity Drive
Hebron, OH 43025
Phone (740) 348-7930

Other names 1

  • Licking Memorial Family Practice Hebron 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
36D2124438Licking Memorial Family Practice Hebron96 Integrity Drive, Suite H, Hebron, OH 43025Certificate of waiverApr 5, 2027

National Provider Directory

National Provider Directory

Locations

96 Integrity Dr
Hebron, OH 43025
Phone (220) 564-7930

96 Integrity Dr
Ste H
Hebron, OH 43025
Phone (220) 564-2100

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1152835200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1689690661",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "96 INTEGRITY DRIVE",
            "city": "HEBRON",
            "state": "OH",
            "postal_code": "43025",
            "telephone_number": "740-348-7930",
            "fax_number": "740-348-7931"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "96 INTEGRITY DRIVE",
            "address_2": "H.",
            "city": "HEBRON",
            "state": "OH",
            "postal_code": "43025",
            "telephone_number": "740-348-7930",
            "fax_number": "740-348-7931"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LICKING MEMORIAL PROFESSIONAL CORP.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-14",
        "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 Hebron",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hebron, 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.