Provider Demographics
NPI:1801286364
Name:MONTGOMERY, RON BLAKE (CNIM)
Entity type:Individual
Prefix:MR
First Name:RON
Middle Name:BLAKE
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 HAWKINS RD
Mailing Address - Street 2:
Mailing Address - City:ARMUCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:30105-2069
Mailing Address - Country:US
Mailing Address - Phone:706-506-9877
Mailing Address - Fax:972-349-1249
Practice Address - Street 1:134 HAWKINS RD
Practice Address - Street 2:
Practice Address - City:ARMUCHEE
Practice Address - State:GA
Practice Address - Zip Code:30105-2069
Practice Address - Country:US
Practice Address - Phone:706-506-9877
Practice Address - Fax:972-349-1249
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2728246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2278OtherCNIM