Provider Demographics
NPI:1760824429
Name:MARY MONTSKO MD LLC
Entity Type:Organization
Organization Name:MARY MONTSKO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTSKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-963-3124
Mailing Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6383
Mailing Address - Country:US
Mailing Address - Phone:813-931-3124
Mailing Address - Fax:813-265-1717
Practice Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6383
Practice Address - Country:US
Practice Address - Phone:813-931-3124
Practice Address - Fax:813-265-1717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276829100Medicaid
FLBK339YMedicare PIN