Provider Demographics
NPI:1104215581
Name:MONTGOMERY GENERAL HOSPITAL INC
Entity Type:Organization
Organization Name:MONTGOMERY GENERAL HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVRILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-774-8770
Mailing Address - Street 1:18101 PRINCE PHILIP DR
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1514
Mailing Address - Country:US
Mailing Address - Phone:301-774-8882
Mailing Address - Fax:
Practice Address - Street 1:18101 PRINCE PHILIP DR
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1514
Practice Address - Country:US
Practice Address - Phone:301-774-8882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD210018Medicare Oscar/Certification