Provider Demographics
NPI:1265476584
Name:MONTGOMERY & RIDDLE EYECARE, PA
Entity Type:Organization
Organization Name:MONTGOMERY & RIDDLE EYECARE, PA
Other - Org Name:MONTGOMERY EYE ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:864-833-0038
Mailing Address - Street 1:22995 HIGHWAY 76 E
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-7529
Mailing Address - Country:US
Mailing Address - Phone:864-833-0038
Mailing Address - Fax:864-833-0520
Practice Address - Street 1:22995 HIGHWAY 76 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7529
Practice Address - Country:US
Practice Address - Phone:864-833-0038
Practice Address - Fax:864-833-0520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCJ9961OtherRAILROAD MEDICARE
SC7427OtherMEDICARE GROUP NUMBER
SCGP3567Medicaid