Basic Information
| Provider Information | |||||||||
| NPI: | 1447346721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTALVO | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | DATMARE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2740 RAY KNIGHT WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317070226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293120698 | ||||||||
| FaxNumber: | 2294387898 | ||||||||
| Practice Location | |||||||||
| Address1: | 2740 RAY KNIGHT WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317070226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293120698 | ||||||||
| FaxNumber: | 2294387898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 02/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 207RG0100X | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 003123270E | 05 | GA | MEDICAID |