Provider Demographics
NPI:1700919024
Name:MONTIAGUE, RAUL RODRIGUEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:RODRIGUEZ
Last Name:MONTIAGUE
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 1:3333 EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9493
Mailing Address - Country:US
Mailing Address - Phone:616-364-4200
Mailing Address - Fax:616-364-7347
Practice Address - Street 1:3333 EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9493
Practice Address - Country:US
Practice Address - Phone:616-364-4200
Practice Address - Fax:616-364-7347
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091372207L00000X
IA34832207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRM091372OtherBCBS
MIM38730025OtherMEDICARE PART B
MI05-0-41-1822-1OtherBCBS PIN
IA1284133Medicaid
IA1284133Medicaid
MI05-0-41-1822-1OtherBCBS PIN
MIM38730025OtherMEDICARE PART B