1164482600 NPI number — DR. ROSARIO MONTGOMERY P.H.D.

Table of content: DR. ROSARIO MONTGOMERY P.H.D. (NPI 1164482600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164482600 NPI number — DR. ROSARIO MONTGOMERY P.H.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
ROSARIO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
P.H.D.
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:
1164482600
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 S 33RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76504-5238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-314-2212
Provider Business Mailing Address Fax Number:
254-265-7504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 S 33RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76504-5238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-314-2212
Provider Business Practice Location Address Fax Number:
254-265-7504
Provider Enumeration Date:
03/27/2006

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: 103TC0700X , with the licence number:  25450 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 680012940 . This is a "RR/MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0403354-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82374P . This is a "BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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