Provider Demographics
NPI:1548251291
Name:MONTAGUE, PHILLIP PATRICK (PT)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:PATRICK
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:PT
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 105132
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30348-5132
Mailing Address - Country:US
Mailing Address - Phone:615-329-2294
Mailing Address - Fax:
Practice Address - Street 1:141 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5093
Practice Address - Country:US
Practice Address - Phone:931-552-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36456201Medicaid
TN36456201Medicaid
TN0406260001Medicare NSC