Provider Demographics
NPI:1538271788
Name:MONTAG, MAURICE J (MD)
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:J
Last Name:MONTAG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0584
Mailing Address - Country:US
Mailing Address - Phone:425-656-4255
Mailing Address - Fax:425-656-4003
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5714
Practice Address - Country:US
Practice Address - Phone:425-228-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017213207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAM686OtherREGENCE B/S PROV #
WA1501303Medicaid
WA185266OtherLABOR&INDUSTRIES PROV #
WA185266OtherLABOR&INDUSTRIES PROV #
WA000103599Medicare ID - Type UnspecifiedMEDICARE PART B PROV #