1689657934 NPI number — BRUCE A MONTGOMERY DO

Table of content: BRUCE A MONTGOMERY DO (NPI 1689657934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689657934 NPI number — BRUCE A MONTGOMERY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
BRUCE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1689657934
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5757 MONCLOVA RD
Provider Second Line Business Mailing Address:
STE 24
Provider Business Mailing Address City Name:
MAUMEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43537-1863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-897-2270
Provider Business Mailing Address Fax Number:
419-897-2290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5757 MONCLOVA RD
Provider Second Line Business Practice Location Address:
STE 24
Provider Business Practice Location Address City Name:
MAUMEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43537-1863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-897-2270
Provider Business Practice Location Address Fax Number:
419-897-2290
Provider Enumeration Date:
11/21/2005

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: 207Q00000X , with the licence number:  34004231M , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000142183 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 02111 . This is a "PARAMOUNT HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0904927 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080155060 . This is a "PALMETTO GBA RAILROAD MED" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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