1114995602 NPI number — TAMARA MARIE MONTGOMERY D.O.

Table of content: TAMARA MARIE MONTGOMERY D.O. (NPI 1114995602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114995602 NPI number — TAMARA MARIE MONTGOMERY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
TAMARA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114995602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 449
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45750-0449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-374-4500
Provider Business Mailing Address Fax Number:
740-374-5887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 E. EIGHTH ST.
Provider Second Line Business Practice Location Address:
SUITE 141
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45750-1656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-374-5580
Provider Business Practice Location Address Fax Number:
740-374-6266
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34-00-7567 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2002638000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2229243 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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