Provider Demographics
NPI:1952477077
Name:MONTGOMERY, CHARLES A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:MONTGOMERY
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 1:109 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-5603
Mailing Address - Country:US
Mailing Address - Phone:423-638-4131
Mailing Address - Fax:423-638-9239
Practice Address - Street 1:109 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-5603
Practice Address - Country:US
Practice Address - Phone:423-638-4131
Practice Address - Fax:423-638-9239
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13954207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN43425OtherTN BLUECARE
TN0000039Medicaid
TN43425OtherTN BLUECARE
TNA97609Medicare UPIN