Provider Demographics
NPI:1639117492
Name:MONTGOMERY, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01235207R00000X, 207R00000X
AL25415208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009929655Medicaid
AL009929635Medicaid
AL51517962OtherBCBS
AL009929675Medicaid
NC1639117492Medicaid
MS04752701Medicaid
LA1673129Medicaid
FL267830600Medicaid
AL04-12178OtherUNITED HEALTH CARE
AL51517961OtherBLUE CROSS
SCNC1841Medicaid
MS04752701Medicaid
AL009929675Medicaid
AL51517961OtherBLUE CROSS
AL04-12178OtherUNITED HEALTH CARE