Basic Information
| Provider Information | |||||||||
| NPI: | 1427059559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C.R.N.P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 HOSPITAL RD 200 | ||||||||
| Address2: | |||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105354561 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 HOSPITAL RD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105354488 | ||||||||
| FaxNumber: | 4105356131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 07/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R137571 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 120363 | 01 | MD | JHHC PROVIDER NUMBER | OTHER | 61760401 | 01 | MD | CAREFIRST MD RENDERING | OTHER | 400427200 | 05 | MD | MEDICAID | R137571 | 01 | MD | MHIP PROVIDER ID | OTHER | 7605-0058 | 01 | MD | CAREFIRST BLUECHOICE | OTHER |