Provider Demographics
NPI:1881674802
Name:MONTELLA, MICHAEL K (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:MONTELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 S MAIN AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-2146
Mailing Address - Country:US
Mailing Address - Phone:570-969-9693
Mailing Address - Fax:570-341-8879
Practice Address - Street 1:743 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18504-2146
Practice Address - Country:US
Practice Address - Phone:570-969-0693
Practice Address - Fax:570-341-8879
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039391E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001161982Medicaid
PA001161982Medicaid
123160Medicare PIN