NPIMap

Organization Active NPI

Licking Memorial Professional Corp.

Doing business as Licking Memorial Occupational Medicine

  • Preventive Medicine/Occupational Environmental Medicine Physician
  • Newark, OH
National Provider Identifier
1891715223
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Preventive Medicine/Occupational Environmental Medicine PhysicianTaxonomy code 2083P0500X
Legal business name
LICKING MEMORIAL PROFESSIONAL CORP.
Doing business as
Licking Memorial Occupational Medicine
Practice address
1865 Tamarack Rd
Newark, OH 43055-2305
Phone
(740) 348-4972
Fax
(740) 348-4991
NPI assigned
Jul 20, 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. Montagense
Title
Executive V.P.
Phone
(740) 348-4000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Preventive Medicine/Occupational Environmental Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2083P0500X Primary

Addresses

Primary practice location

1865 Tamarack Rd
Newark, OH 43055-2305

Mailing address

1865 Tamarack Rd
Newark, OH 43055-2305
Phone (740) 348-4972

Other identifiers 1

IdentifierTypeStateIssuer
2354134MedicaidOH

Other names 1

  • Licking Memorial Occupational 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

Locations

1865 Tamarack Rd
Newark, OH 43055
Phone (220) 564-4972

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": "1891715223",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1865 TAMARACK RD",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430552305",
            "telephone_number": "740-348-4972",
            "fax_number": "740-348-4991"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1865 TAMARACK RD",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430552305",
            "telephone_number": "740-348-4972",
            "fax_number": "740-348-4991"
        }
    ],
    "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": "MONTAGENSE",
        "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": "2083P0500X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Preventive Medicine, Preventive Medicine/Occupational Environmental Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2354134",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Licking Memorial Occupational 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.