Basic Information
| Provider Information | |||||||||
| NPI: | 1750352159 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONT GREEN ANESTHESIOLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3180 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372976072 | ||||||||
| FaxNumber: | 9372930969 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 S. EDWIN C. MOSES BLVD. | ||||||||
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| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454081462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372218000 | ||||||||
| FaxNumber: | 9372218529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | KAMINSKI | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372976072 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2600573 | 05 | OH | MEDICAID | 2600555 | 05 | OH | MEDICAID | 2600546 | 05 | OH | MEDICAID | 2600564 | 05 | OH | MEDICAID | 000000381907 | 01 | OH | ANTHEM | OTHER | DD8829 | 01 | OH | RAILROAD MEDICARE | OTHER | 565255007005 | 01 | OH | MEDICAL MUTUAL OF OHIO | OTHER | 2600537 | 05 | OH | MEDICAID |