1255343331 NPI number — MR. MATTHEW CARL MONTGOMERY CRNA, MS

Table of content: JOHN POLK DUMAS (NPI 1376247171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255343331 NPI number — MR. MATTHEW CARL MONTGOMERY CRNA, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
MATTHEW
Provider Middle Name:
CARL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA, MS
Provider Gender Code:
M

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:
1255343331
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 KINGSLEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68467-4129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-440-4141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2222 N LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68467-1030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-362-6671
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2006

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: 367500000X , with the licence number:  100902 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NE 901660 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00273623 . This is a "RAILROAD NUMBER" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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