Provider Demographics
NPI:1851697023
Name:MARK H MONTGOMERY MD PA
Entity Type:Organization
Organization Name:MARK H MONTGOMERY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:H
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-495-6200
Mailing Address - Street 1:9240 BONITA BEACH RD SE
Mailing Address - Street 2:SUITE 1106
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4249
Mailing Address - Country:US
Mailing Address - Phone:239-495-6200
Mailing Address - Fax:239-495-6247
Practice Address - Street 1:9240 BONITA BEACH RD SE
Practice Address - Street 2:SUITE 1106
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4249
Practice Address - Country:US
Practice Address - Phone:239-495-6200
Practice Address - Fax:239-495-6247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84347261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA95011Medicare UPIN