Basic Information
| Provider Information | |||||||||
| NPI: | 1093796690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 CLARK ST NE | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350551921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567391759 | ||||||||
| FaxNumber: | 2567390027 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 CLARK ST NE | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350551953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567343202 | ||||||||
| FaxNumber: | 2567344668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10441 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000026282 | 05 | AL | MEDICAID | 51026282 | 01 | AL | BCBS OF AL | OTHER | E869 | 01 | MEDICARE GROUP # | OTHER | 1114238243 | 05 | AL | MEDICAID |