Provider Demographics
NPI:1275904237
Name:MONTGOMERY, BETH ANN
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S COUNTY ROAD 1
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-9746
Mailing Address - Country:US
Mailing Address - Phone:419-443-0710
Mailing Address - Fax:419-443-0576
Practice Address - Street 1:1500 S COUNTY ROAD 1
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-9746
Practice Address - Country:US
Practice Address - Phone:419-443-0710
Practice Address - Fax:419-443-0576
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03108174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist