Provider Demographics
NPI:1508046038
Name:DAVID M MONTGOMERY MD INC
Entity Type:Organization
Organization Name:DAVID M MONTGOMERY MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-453-7117
Mailing Address - Street 1:403 CLARENDON AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4505
Mailing Address - Country:US
Mailing Address - Phone:330-453-7117
Mailing Address - Fax:330-453-5995
Practice Address - Street 1:403 CLARENDON AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4505
Practice Address - Country:US
Practice Address - Phone:330-453-7117
Practice Address - Fax:330-453-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35029375207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0136221Medicaid
OH9172401Medicare PIN
OH0136221Medicaid