Provider Demographics
NPI:1144291923
Name:INTERVENTIONAL THERAPEUTICS INSTITUTE, LLC
Entity type:Organization
Organization Name:INTERVENTIONAL THERAPEUTICS INSTITUTE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-791-6895
Mailing Address - Street 1:201 DEFENSE HWY STE 205
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7096
Mailing Address - Country:US
Mailing Address - Phone:855-527-7246
Mailing Address - Fax:833-810-1165
Practice Address - Street 1:5102 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2030
Practice Address - Country:US
Practice Address - Phone:855-527-7246
Practice Address - Fax:855-527-7246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1241261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAS14960633Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID