Basic Information
| Provider Information | |||||||||
| NPI: | 1487665204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | ELDRIDGE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N EAGLE CREEK DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592634341 | ||||||||
| FaxNumber: | 8592637441 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404221823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592367000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 16883 | KY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 64-168834 | 05 | KY | MEDICAID |