NPIMap

Organization Active NPI

Licking Memorial Professional Corporation

  • Dermatology Physician
  • Pataskala, OH
National Provider Identifier
1700291416
Registry record updated Jun 23, 2014
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 Pataskala
Practice address
1 Healthy PL
Suite 205
Pataskala, OH 43062-7067
Phone
(740) 348-1930
Fax
(740) 348-1931
NPI assigned
Jun 23, 2014
Organization subpart
Yes
Parent organization
LICKING MEMORIAL PROFESSIONAL CORPORATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 23, 2014

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

Authorized official

Name
Cynthia L. Webster
Title
VP Financial Services
Phone
(740) 348-4518

Specialties & licenses 1

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

Addresses

Primary practice location

1 Healthy PL
Suite 205
Pataskala, OH 43062-7067

Mailing address

1 Healthy PL
Suite 205
Pataskala, OH 43062-7067
Phone (740) 348-1930

Other names 1

  • Licking Memorial Dermatology Pataskala 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
Part of
Licking Memorial Profes

Locations

1 Healthy Pl
Ste 205
Pataskala, OH 43062
Phone (740) 348-1930

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1403481600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1403481600000",
    "number": "1700291416",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 HEALTHY PL",
            "address_2": "SUITE 205",
            "city": "PATASKALA",
            "state": "OH",
            "postal_code": "430627067",
            "telephone_number": "740-348-1930",
            "fax_number": "740-348-1931"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 HEALTHY PL",
            "address_2": "SUITE 205",
            "city": "PATASKALA",
            "state": "OH",
            "postal_code": "430627067",
            "telephone_number": "740-348-1930",
            "fax_number": "740-348-1931"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LICKING MEMORIAL PROFESSIONAL CORPORATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LICKING MEMORIAL PROFESSIONAL CORPORATION",
        "enumeration_date": "2014-06-23",
        "last_updated": "2014-06-23",
        "status": "A",
        "authorized_official_last_name": "WEBSTER",
        "authorized_official_first_name": "CYNTHIA",
        "authorized_official_middle_name": "L.",
        "authorized_official_title_or_position": "VP FINANCIAL SERVICES",
        "authorized_official_telephone_number": "740-348-4518"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Licking Memorial Dermatology Pataskala",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pataskala, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 23, 2014; 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.