Provider Demographics
NPI:1407146350
Name:CRAIG S MONTGOMERY PHD PC
Entity Type:Organization
Organization Name:CRAIG S MONTGOMERY PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:503-661-7733
Mailing Address - Street 1:1326 NW CIVIC DR
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5569
Mailing Address - Country:US
Mailing Address - Phone:503-661-7733
Mailing Address - Fax:503-661-7890
Practice Address - Street 1:1326 NW CIVIC DR
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5569
Practice Address - Country:US
Practice Address - Phone:503-661-7733
Practice Address - Fax:503-661-7890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR530261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR58679Medicare UPIN