Basic Information
| Provider Information | |||||||||
| NPI: | 1396722344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTANA | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35364 EAGEL WAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606781353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002221442 | ||||||||
| FaxNumber: | 5177877199 | ||||||||
| Practice Location | |||||||||
| Address1: | 5454 HOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199332270 | ||||||||
| FaxNumber: | 2198522515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 07/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 041-287128 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 28164876A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200842370 | 05 | IN | MEDICAID |