# LICKING MEMORIAL PROFESSIONAL CORPORATION

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Licking Memorial Family Practice-Granville
- **Organization subpart:** No

## Provider details

- **NPI number:** 1043244965
- **Authorized official:** ROBERT A. MONTAGNESE (EXECUTIVE V.P.)
- **Authorized official phone:** (740) 348-4000

## Contact information

- **Practice address:** 1264 WEAVER DR, GRANVILLE, OH 43023-1257
- **Practice address phone:** (740) 348-1940
- **Practice address fax:** (740) 348-1941
- **Mailing address:** 1264 WEAVER DR, GRANVILLE, OH 43023-1257
- **Mailing address phone:** (740) 348-1940
- **Mailing address fax:** (740) 348-1941

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 07/10/2006
- **Last updated:** 08/22/2020