Basic Information
| Provider Information | |||||||||
| NPI: | 1750432092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTGOMERY EKG LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18101 PRINCE PHILIP DR | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017748882 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18101 PRINCE PHILIP DR | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017748882 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| AuthorizedOfficialLastName: | CONNOLLY | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3017748882 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | KFA8MO | 01 | MD | BLUE SHIELD | OTHER | H954 | 01 | DC | GHI | OTHER | DA2369 | 01 | MD | RAILROAD MEDICARE | OTHER |