Basic Information
| Provider Information | |||||||||
| NPI: | 1902048234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | VERNESHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 LINCOLN PARK BLVD STE 220 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454296404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372944487 | ||||||||
| FaxNumber: | 9372942255 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 W. FAIRCHILD ST. | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174317650 | ||||||||
| FaxNumber: | 2174317792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 49452 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036134565 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34887709 | 05 | CO | MEDICAID |