1205977428 NPI number — MONTFORD MEDICAL SERVICES

Table of content: (NPI 1205977428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205977428 NPI number — MONTFORD MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTFORD MEDICAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205977428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2181
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31099-2181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-971-1299
Provider Business Mailing Address Fax Number:
478-953-6879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 TRELLIS WALK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31028-8510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-971-1299
Provider Business Practice Location Address Fax Number:
478-953-6879
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MONTFORD
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
LEVESTER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
478-971-1299

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1238 . This is a "LICENSE NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00546268A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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