Provider Demographics
NPI:1548462021
Name:MONTGOMERY AND ASSOCIATES MD
Entity type:Organization
Organization Name:MONTGOMERY AND ASSOCIATES MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-679-1600
Mailing Address - Street 1:300 HEALTH PARK BLVD
Mailing Address - Street 2:STE 1006
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3707
Mailing Address - Country:US
Mailing Address - Phone:386-679-1600
Mailing Address - Fax:
Practice Address - Street 1:300 HEALTH PARK BLVD
Practice Address - Street 2:STE 1006
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3707
Practice Address - Country:US
Practice Address - Phone:386-679-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0467Medicare ID - Type UnspecifiedMEDICARE LEGACY #