Basic Information
Provider Information | |||||||||
NPI: | 1720032444 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONTGOMERY | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RADEMACHER | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1229 C AVE E | ||||||||
Address2: |   | ||||||||
City: | OSKALOOSA | ||||||||
State: | IA | ||||||||
PostalCode: | 525774246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6416723100 | ||||||||
FaxNumber: | 6416723111 | ||||||||
Practice Location | |||||||||
Address1: | 1229 C AVE E | ||||||||
Address2: |   | ||||||||
City: | OSKALOOSA | ||||||||
State: | IA | ||||||||
PostalCode: | 525774246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6416723100 | ||||||||
FaxNumber: | 6416723111 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 01/31/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 3571 | IA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 208M00000X | 3571 | IA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 0442285 | 05 | IA |   | MEDICAID |