Basic Information
| Provider Information | |||||||||
| NPI: | 1679054696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 BORMET DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083464044 | ||||||||
| FaxNumber: | 7083463287 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 W 95TH ST STE 308 | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083464040 | ||||||||
| FaxNumber: | 7083463287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2018 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 041472495 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | 246ZC0007X | 238000654 | IL | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
ID Information
| ID | Type | State | Issuer | Description | 041472495 | 01 | IL | IL RN LICENSE | OTHER | 238000654 | 01 | IL | IL SA LICENSE | OTHER |