Basic Information
| Provider Information | |||||||||
| NPI: | 1356367536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTAGUE | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 283 E 930 S | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840585001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012256246 | ||||||||
| FaxNumber: | 8012251525 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 E MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847902123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356884000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 08/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 174855-1205 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 11253 | NV | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | 174855-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085D0003X | 174855-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging |
ID Information
| ID | Type | State | Issuer | Description | 107007775101 | 01 | UT | IHC | OTHER | 907907 | 01 | UT | DMBA | OTHER | 870487570004 | 05 | UT | MEDICAID | 59284499602001 | 01 | UT | BLUE CROSS | OTHER | 870487570MD1 | 01 | UT | EMIA | OTHER |