Provider Demographics
NPI:1679054696
Name:MONTGOMERY, TRAVIS (RNFA)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 BORMET DR STE 204
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8399
Mailing Address - Country:US
Mailing Address - Phone:708-346-4044
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:4400 W 95TH ST STE 308
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2660
Practice Address - Country:US
Practice Address - Phone:708-346-4040
Practice Address - Fax:708-346-3287
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041472495163WR0006X
IL238000654246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041472495OtherIL RN LICENSE
IL238000654OtherIL SA LICENSE