Basic Information
Provider Information | |||||||||
NPI: | 1033503255 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONTAG | ||||||||
FirstName: | NATHANIEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 355 W 16TH ST | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462022207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179637077 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 500 GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | ENGLEWOOD | ||||||||
State: | NJ | ||||||||
PostalCode: | 076314967 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2015672277 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2015 | ||||||||
LastUpdateDate: | 04/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 296383-1 | NY | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 02005347A | IN | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208100000X | 25MB10420400 | NJ | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.