Organization
LICKING MEMORIAL PROFESSIONAL CORPORATION
Active
Other names
Licking Memorial Dermatology
Organization subpart
No
Provider details
NPI number
Authorized official
ROBERT A. MONTAGNESE (EXECUTIVE ICE PRESIDENT)
(740) 348-4000
Entity
Organization
Contact information
Practice address
36 MCMILLEN DR, NEWARK, OH 43055-3666
(740) 348-1755
(740) 348-1756
Mailing address
36 MCMILLEN DR, NEWARK, OH 43055-3666
(740) 348-1755
(740) 348-1756
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2527975
—
OH
Enumeration date
06/07/2006
Last updated
08/22/2020
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