1437291226 NPI number — DOUGLAS J MONTGOMERY PA-C

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437291226 NPI number — DOUGLAS J MONTGOMERY PA-C

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MONTGOMERY

Provider First Name:

DOUGLAS

Provider Middle Name:

J

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

PA-C

Provider Gender Code:

M

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:

1437291226

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

09/22/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

237 WILLIAM HOWARD TAFT, PHYS DIV

Provider Second Line Business Mailing Address:

2ND FL, CBO2-3, ATTN: CREDENTIALING

Provider Business Mailing Address City Name:

CINCINNATI

Provider Business Mailing Address State Name:

OH

Provider Business Mailing Address Postal Code:

45219-2906

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

513-792-7445

Provider Business Mailing Address Fax Number:

513-791-4042

Provider First Line Business Practice Location Address:

9250 BLUE ASH RD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CINCINNATI

Provider Business Practice Location Address State Name:

OH

Provider Business Practice Location Address Postal Code:

45242-6822

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

513-792-7445

Provider Business Practice Location Address Fax Number:

513-791-4042

Provider Enumeration Date:

02/12/2007

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 363AS0400X , with the licence number:  50.000196 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1630393 . This is a "GATEWAY HEALTH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: P10000897204 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 752112 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 0077329 . This is a "MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 272352575063 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 5188071 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 791940 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: H155980 . This is a "MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: K052931 . This is a "MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: P01191326 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: P01252598 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".