Basic Information
| Provider Information | |||||||||
| NPI: | 1124260211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTGOMERY DERMATOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 491 ALLENDALE RD | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194061426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102651166 | ||||||||
| FaxNumber: | 6102651186 | ||||||||
| Practice Location | |||||||||
| Address1: | 491 ALLENDALE RD | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194061426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102651166 | ||||||||
| FaxNumber: | 6102651186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2009 | ||||||||
| LastUpdateDate: | 04/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | ILYAS | ||||||||
| AuthorizedOfficialFirstName: | ERUM | ||||||||
| AuthorizedOfficialMiddleName: | NASEEM | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2156944851 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD424557 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.