Provider Demographics
NPI:1497133458
Name:KETCHUM, MONTE (DO)
Entity Type:Individual
Prefix:
First Name:MONTE
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SAINT VINCENTS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1638
Mailing Address - Country:US
Mailing Address - Phone:205-939-3699
Mailing Address - Fax:205-581-7155
Practice Address - Street 1:805 SAINT VINCENTS DR STE 100
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205
Practice Address - Country:US
Practice Address - Phone:205-939-3699
Practice Address - Fax:205-581-7155
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.1819207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine