Provider Demographics
NPI:1023205754
Name:MONTGOMERY MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:MONTGOMERY MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLSOPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-486-2842
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IN
Mailing Address - Zip Code:47558-0102
Mailing Address - Country:US
Mailing Address - Phone:812-486-2842
Mailing Address - Fax:812-486-2784
Practice Address - Street 1:542 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IN
Practice Address - Zip Code:47558-5745
Practice Address - Country:US
Practice Address - Phone:812-486-2842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200864610AMedicaid
IN254690Medicare PIN