Basic Information
| Provider Information | |||||||||
| NPI: | 1649290370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTANA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 HIGHLAND DR | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981093326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123752167 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18780 INTERSTATE 20 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751033593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035674841 | ||||||||
| FaxNumber: | 9036061201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD00046731 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M-2027 | GU | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036112106 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | R2927 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P02503065 | 01 | TX | MEDICARE RAILROAD | OTHER |