Provider Demographics
NPI:1083645220
Name:MONTGOMERY INTERNAL MEDICINE ASSOC., P.A.
Entity Type:Organization
Organization Name:MONTGOMERY INTERNAL MEDICINE ASSOC., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MALTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-774-6655
Mailing Address - Street 1:2901 OLNEY SANDY SPRING RD
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1521
Mailing Address - Country:US
Mailing Address - Phone:301-774-6655
Mailing Address - Fax:301-774-5652
Practice Address - Street 1:2901 OLNEY SANDY SPRING RD
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1521
Practice Address - Country:US
Practice Address - Phone:301-774-6655
Practice Address - Fax:301-774-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD9112715Medicaid
MD409904Medicare ID - Type Unspecified