Provider Demographics
NPI:1487816534
Name:MONTGOMERY, RYAN J (MSPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 GREENUP AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-1953
Mailing Address - Country:US
Mailing Address - Phone:606-324-0540
Mailing Address - Fax:606-324-0616
Practice Address - Street 1:2700 GREENUP AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-1953
Practice Address - Country:US
Practice Address - Phone:606-324-0540
Practice Address - Fax:606-324-0616
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT 2701225100000X
KY005341225100000X
OHPT012319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013985Medicaid
KY5021308Medicare PIN
WV3810013985Medicaid
KY5024412Medicare PIN
WVP00641907Medicare PIN