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LICKING MEMORIAL GERIATRIC MEDICINE AT AUTUMN
NPI 1235311358
Family Medicine - Geriatric Medicine in Newark, OH

Active since November 30, 2007CLIA 36D2179016 · Waiver
17 FORRY ST, NEWARK, OH 43055(740) 348-7935(740) 348-7936 Get Directions Write a Review

NPPES record last updated: November 30, 2007. Verified against the NPPES registry weekly; last sync: September 13, 2026.

About Licking Memorial Geriatric Medicine At Autumn NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

LICKING MEMORIAL GERIATRIC MEDICINE AT AUTUMN (NPI 1235311358) is a healthcare organization registered as a geriatric medicine in Newark, Ohio and active in the NPI registry since November 2007. The organization holds a CLIA Waiver certificate valid through February 12, 2028 and lists Thomas N. Poulson, Cfo, as its authorized official.

NPPES Registry Identity

NPI1235311358
Entity TypeOrganization
Primary Taxonomy207QG0300X
Legal Business NameLICKING MEMORIAL PROFESSIONAL CORP.
Location Address17 FORRY STNewark, OH 43055-4004
Mailing Address17 Forry StNewark, OH 43055-4004 · (740) 348-7935 · Fax (740) 348-7936
Phone(740) 348-7935
Fax(740) 348-7936
Organization SubpartNo
Authorized OfficialThomas N. PoulsonCfo · (740) 348-4110
Enumeration DateNovember 30, 2007
✔ NPI 1235311358 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyFamily Medicine · Geriatric MedicineAllopathic & Osteopathic Physicians
Taxonomy Code207QG0300X
Definition
A family medicine physician with special knowledge of the aging process and special skills in the diagnostic, therapeutic, preventive and rehabilitative aspects of illness in the elderly. This specialist cares for geriatric patients in the patient's home, the office, long-term care settings such as nursing homes, and the hospital.
17 FORRY ST, Newark, OH 43055
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Other Names 1

Doing Business AsLicking Memorial Geriatric Medicine At Autumn

Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X SINGLE SPECIALTY GROUP

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 36D2179016

Licking Memorial Professional Corp Fp Drpk2 · Newark, OH
Active · expires Feb 12, 2028
CLIA Number36D2179016
Laboratory TypePhysician Office
Certificate Effective DateFebruary 13, 2026
Certificate Expiration DateFebruary 12, 2028
Laboratory DirectorMarita Moore
Laboratory Phone(220) 564-4824
Laboratory LocationLicking Memorial Professional Corp Fp Drpk21272 W Main St, Ste 206 Building 2, Newark, OH 43055
CLIA data matches this NPI record on: Name
This certificate is issued to a laboratory to perform only waived tests.

Other Providers at the Same Location NPPES 2

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

NEWARK NH LLC
Skilled Nursing Facility
17 FORRY ST
NEWARK, OH 43055
Licking County (740) 345-9197
ALTERCARE NEWARK SOUTH, INC.
Skilled Nursing Facility
17 FORRY ST
NEWARK, OH 43055
Licking County (740) 345-9197

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Licking Memorial Professional Corp.'s NPI number?

The NPI number for Licking Memorial Professional Corp. is 1235311358. It was assigned to this organization in the NPPES registry on November 30, 2007. The provider is doing business as Licking Memorial Geriatric Medicine At Autumn.

Where is Licking Memorial Professional Corp. located?

Licking Memorial Professional Corp. is located at 17 Forry St, Newark, OH 43055. The listed phone number is (740) 348-7935.

What is Licking Memorial Professional Corp.'s specialty?

The primary specialty registered for this NPI is Family Medicine, specializing in Geriatric Medicine, with taxonomy code 207QG0300X.

Does Licking Memorial Professional Corp. hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 36D2179016) is associated with this NPI, valid through February 12, 2028. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Licking Memorial Professional Corp. was last updated on November 30, 2007. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 18 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.