Basic Information
| Provider Information | |||||||||
| NPI: | 1801845193 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PARK WEST BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443204218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308699777 | ||||||||
| FaxNumber: | 3308690052 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PARK WEST BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443204218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308699777 | ||||||||
| FaxNumber: | 3308690052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 11/18/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35042780M | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0950029 | 05 | OH | MEDICAID |