Provider Demographics
NPI:1831471051
Name:MONTGOMERY BRAIN AND SPINE
Entity Type:Organization
Organization Name:MONTGOMERY BRAIN AND SPINE
Other - Org Name:CENTER FOR BRAIN AND SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:F
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-826-0500
Mailing Address - Street 1:PO BOX 1757
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21203-1757
Mailing Address - Country:US
Mailing Address - Phone:301-585-7900
Mailing Address - Fax:240-766-8088
Practice Address - Street 1:1300 SPRING STREET
Practice Address - Street 2:SUITE 210
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3616
Practice Address - Country:US
Practice Address - Phone:301-585-7900
Practice Address - Fax:240-766-8088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0067880207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD550603400Medicaid
DC066767900Medicaid
MD6749700001Medicare NSC