Basic Information
| Provider Information | |||||||||
| NPI: | 1437291226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 237 WILLIAM HOWARD TAFT, PHYS DIV | ||||||||
| Address2: | 2ND FL, CBO2-3, ATTN: CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137927445 | ||||||||
| FaxNumber: | 5137914042 | ||||||||
| Practice Location | |||||||||
| Address1: | 9250 BLUE ASH RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452426822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137927445 | ||||||||
| FaxNumber: | 5137914042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 09/22/2017 | ||||||||
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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 | 363AS0400X | 50.000196 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1630393 | 01 | OH | GATEWAY HEALTH | OTHER | P10000897204 | 01 | OH | BUCKEYE | OTHER | 752112 | 01 | OH | WELLCARE | OTHER | 0077329 | 01 | OH | MEDICAID | OTHER | 272352575063 | 01 | OH | CARESOURCE | OTHER | 5188071 | 01 | OH | AETNA | OTHER | 791940 | 01 | OH | ANTHEM | OTHER | H155980 | 01 | OH | MEDICARE | OTHER | K052931 | 01 | KY | MEDICARE | OTHER | P01191326 | 01 | OH | RAILROAD MEDICARE | OTHER | P01252598 | 01 | KY | RAILROAD MEDICARE | OTHER |