Provider Demographics
NPI:1437190600
Name:MONTGOMERY, MATTHEW L (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
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 1:100 PENN ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-1956
Mailing Address - Country:US
Mailing Address - Phone:717-646-1117
Mailing Address - Fax:717-632-4748
Practice Address - Street 1:100 PENN ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-1956
Practice Address - Country:US
Practice Address - Phone:717-646-1117
Practice Address - Fax:717-632-4748
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053492L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016392900004Medicaid
900256Medicare ID - Type Unspecified
PA0016392900004Medicaid