Provider Demographics
NPI:1972762995
Name:MONTGOMERY CORNELISON, LAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAINE
Middle Name:
Last Name:MONTGOMERY CORNELISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAINE
Other - Middle Name:
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:7190 CRESTWOOD BLVD
Practice Address - Street 2:KAISER PERMANENTE FREDERICK MEDICAL CENTER
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-7314
Practice Address - Country:US
Practice Address - Phone:240-529-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249806207Q00000X
DCMD040239207Q00000X
MDD72798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine