Provider Demographics
NPI:1952703969
Name:MONTGOMERY, MARC
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:MONTGOMERY
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 1:1108 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1243
Mailing Address - Country:US
Mailing Address - Phone:312-961-4894
Mailing Address - Fax:708-383-6948
Practice Address - Street 1:1108 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1243
Practice Address - Country:US
Practice Address - Phone:312-961-4894
Practice Address - Fax:708-383-6948
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide