Basic Information
| Provider Information | |||||||||
| NPI: | 1851349179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDEN | ||||||||
| FirstName: | MONTGOMERY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 PROFESSIONAL LANE | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343473404 | ||||||||
| FaxNumber: | 3343930613 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PROFESSIONAL LANE | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343473404 | ||||||||
| FaxNumber: | 3346930613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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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 | 207Q00000X | 00011984 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000028378 | 05 | AL | MEDICAID | 51028378 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |