1891104188 NPI number — SOUTHWEST OTO AND HEAD & NECK SURGERY,PSC

Table of content: INGO D MONTGOMERY MS, BA, LICDC, LSW (NPI 1427211606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891104188 NPI number — SOUTHWEST OTO AND HEAD & NECK SURGERY,PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST OTO AND HEAD & NECK SURGERY,PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1891104188
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2000
Provider Second Line Business Mailing Address:
PMB 137
Provider Business Mailing Address City Name:
MERCEDITA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-290-3333
Provider Business Mailing Address Fax Number:
787-290-4444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
TORRE MED SAN LUCAS
Provider Second Line Business Practice Location Address:
AVE. TITO CASTRO
Provider Business Practice Location Address City Name:
PONCE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00716-4728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-290-3333
Provider Business Practice Location Address Fax Number:
787-290-4444
Provider Enumeration Date:
08/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DOMENECH FAGUNDO
Authorized Official First Name:
EDGAR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
787-290-3333

Provider Taxonomy Codes

  • Taxonomy code: 207YX0007X , with the licence number:  13247 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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