Provider Demographics
NPI:1083609747
Name:MONTGOMERY, BENJAMIN E (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:E
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 W LAFAYETTE AVE STE D
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3710
Mailing Address - Country:US
Mailing Address - Phone:217-479-0290
Mailing Address - Fax:
Practice Address - Street 1:1606 W LAFAYETTE AVE STE D
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3710
Practice Address - Country:US
Practice Address - Phone:217-479-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-109933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine