NPIMap

Organization Active NPI

Licking Memorial Professional Corporation

Doing business as Licking Memorial Behavioral Health

  • Psychiatry Physician
  • Newark, OH
National Provider Identifier
1932149150
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
LICKING MEMORIAL PROFESSIONAL CORPORATION
Doing business as
Licking Memorial Behavioral Health
Practice address
200 Messimer Dr
Newark, OH 43055-3627
Phone
(740) 348-4870
Fax
(740) 348-4871
NPI assigned
Jun 7, 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 Vice President
Phone
(740) 348-4000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry Physician 2084P0800X NU Primary

Addresses

Primary practice location

200 Messimer Dr
Newark, OH 43055-3627

Mailing address

200 Messimer Dr
Newark, OH 43055-3627
Phone (740) 348-4870

Other identifiers 1

IdentifierTypeStateIssuer
0118992MedicaidOH

Other names 1

  • Licking Memorial Behavioral Health 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

200 Messimer Dr
Newark, OH 43055
Phone (740) 348-4870

NPI Registry JSON

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

{
    "created_epoch": "1149638400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1932149150",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 MESSIMER DR",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430553627",
            "telephone_number": "740-348-4870",
            "fax_number": "740-348-4871"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 MESSIMER DR",
            "city": "NEWARK",
            "state": "OH",
            "postal_code": "430553627",
            "telephone_number": "740-348-4870",
            "fax_number": "740-348-4871"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LICKING MEMORIAL PROFESSIONAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-07",
        "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 VICE PRESIDENT",
        "authorized_official_telephone_number": "740-348-4000"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0118992",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Licking Memorial Behavioral Health",
            "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.