1538221023 NPI number — MR. WILLIAM SHERMAN MONTGOMERY CRNA

Table of content: MR. WILLIAM SHERMAN MONTGOMERY CRNA (NPI 1538221023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538221023 NPI number — MR. WILLIAM SHERMAN MONTGOMERY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
WILLIAM
Provider Middle Name:
SHERMAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1538221023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2081
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESTONSBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41653-2081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-791-0179
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11203 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41649-0910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-285-6400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2006

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:  1039197 696 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 65927568 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 430018294 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100037180 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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