Provider Demographics
NPI:1144390345
Name:MONTGOMERY FAMILY PRACTICE, INC
Entity Type:Organization
Organization Name:MONTGOMERY FAMILY PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MD
Authorized Official - Prefix:DR
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:S
Authorized Official - Last Name:KUBALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-791-1201
Mailing Address - Street 1:10550 MONTGOMERY RD
Mailing Address - Street 2:# 12
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242
Mailing Address - Country:US
Mailing Address - Phone:513-791-1201
Mailing Address - Fax:513-791-1231
Practice Address - Street 1:10550 MONTGOMERY RD STE 11
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4495
Practice Address - Country:US
Practice Address - Phone:513-791-1201
Practice Address - Fax:513-791-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057045207Q00000X
OH35067638207Q00000X
OH350728718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2274891Medicaid
OH9239961Medicare PIN
G09767Medicare UPIN
OH2274891Medicaid
G75578Medicare UPIN