Provider Demographics
NPI:1497865893
Name:MONTGOMERY OTOLARYNGOLOGY LLP
Entity Type:Organization
Organization Name:MONTGOMERY OTOLARYNGOLOGY LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RODGER
Authorized Official - Middle Name:
Authorized Official - Last Name:EGELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:334-834-7221
Mailing Address - Street 1:1722 PINE ST
Mailing Address - Street 2:SUITE 804
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1103
Mailing Address - Country:US
Mailing Address - Phone:334-834-7221
Mailing Address - Fax:
Practice Address - Street 1:1722 PINE ST
Practice Address - Street 2:SUITE 804
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1103
Practice Address - Country:US
Practice Address - Phone:334-834-7221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528801560Medicaid
ALD507OtherMEDICARE PTAN