Provider Demographics
NPI:1083762819
Name:STEFAN MONTGOMERY MD FAMILY & SPORTS MEDICINE, PA
Entity Type:Organization
Organization Name:STEFAN MONTGOMERY MD FAMILY & SPORTS MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEFAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-531-8500
Mailing Address - Street 1:PO BOX 1785
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1785
Mailing Address - Country:US
Mailing Address - Phone:803-395-4499
Mailing Address - Fax:803-395-4480
Practice Address - Street 1:2850 PELHAM CT
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1400
Practice Address - Country:US
Practice Address - Phone:803-531-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC000000199439OtherUNISON
SC000000199441OtherUNISON
SCDE2500Medicaid
SC20059042OtherSELECT HEALTH
SC7455015OtherCIGNA
SC272779Medicaid
SC7259579OtherAETNA
SCGP4594Medicaid
SC7455015OtherCIGNA
SC7259579OtherAETNA
SC272779Medicaid
SC20059042OtherSELECT HEALTH
SC5911960001Medicare NSC