Provider Demographics
NPI:1114958212
Name:MONTGOMERY, ROBERT C (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
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 1:737 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0001
Mailing Address - Country:US
Mailing Address - Phone:701-234-2000
Mailing Address - Fax:701-234-3740
Practice Address - Street 1:737 BROADWAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:701-234-3740
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28421208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D26149Medicare UPIN