Provider Demographics
NPI:1679559223
Name:MONTGOMERY, KYLE DAVID (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DAVID
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-926-3115
Mailing Address - Fax:215-926-3100
Practice Address - Street 1:2317 E WESTMORELAND ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19134-4529
Practice Address - Country:US
Practice Address - Phone:215-926-3115
Practice Address - Fax:215-926-3100
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2014-01-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD064400L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA080164274OtherRAILROAD MEDICARE
PA30036753OtherKEYSTONE MERCY HEALTH PLA
PA2319021OtherAETNA HMO
PA6052OtherBRAVO HEALTH
PA2Y7472OtherHEALTH NET
PA028886OtherHIGHMARK BLUE SHIELD
PA497977OtherCOVENTRY HEALTH AMERICA
PA30036754OtherKEYSTONE MERCY HEALTH PLA
PA5466743OtherAETNA PPO
PA001822599Medicaid
PA1458249OtherAETNA HMO
PA30036754OtherKEYSTONE MERCY HEALTH PLA
PA001822599Medicaid