NPIMap

Organization Active NPI

Licking Memorial Professional Corp

  • Internal Medicine Physician
  • Newark, OH
National Provider Identifier
1730109166
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
LICKING MEMORIAL PROFESSIONAL CORP
Practice address
120 McMillen Dr
Newark, OH 43055-1809
Phone
(740) 348-4800
Fax
(740) 348-4801
NPI assigned
Jul 20, 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 V.P
Phone
(740) 348-4000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X Primary

Addresses

Primary practice location

120 McMillen Dr
Newark, OH 43055-1809

Mailing address

120 McMillen Dr
Newark, OH 43055-1809
Phone (740) 348-4800

Other names 1

  • Licking Memorial Internal Medicine 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": "1153353600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1730109166",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 MCMILLEN DR",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430551809",
            "telephone_number": "740-348-4800",
            "fax_number": "740-348-4801"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 MCMILLEN DR",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430551809",
            "telephone_number": "740-348-4800",
            "fax_number": "740-348-4801"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LICKING MEMORIAL PROFESSIONAL CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-20",
        "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": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Licking Memorial Internal Medicine",
            "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.