Provider Demographics
NPI:1922032200
Name:MONTANA, JAMES SAMUEL
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:SAMUEL
Last Name:MONTANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CONAN ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1145
Mailing Address - Country:US
Mailing Address - Phone:218-365-7900
Mailing Address - Fax:218-365-7975
Practice Address - Street 1:300 W CONAN ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1145
Practice Address - Country:US
Practice Address - Phone:218-365-7900
Practice Address - Fax:218-365-7975
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38029207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN311726000Medicaid
MN311726000Medicaid
MN110007970Medicare PIN