Basic Information
Provider Information
NPI: 1003005166
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MONTGOMERY
FirstName: MICHAEL
MiddleName: ANDREW
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 237 26TH ST
Address2:  
City: OGDEN
State: UT
PostalCode: 844013105
CountryCode: US
TelephoneNumber: 8016253700
FaxNumber:  
Practice Location
Address1: 237 26TH ST
Address2:  
City: OGDEN
State: UT
PostalCode: 844013105
CountryCode: US
TelephoneNumber: 8016253700
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/15/2007
LastUpdateDate: 10/15/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
390200000X  Y Student, Health CareStudent in an Organized Health Care Education/Training Program 

ID Information
IDTypeStateIssuerDescription
87600030800705UT MEDICAID


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