Basic Information
| Provider Information | |||||||||
| NPI: | 1972762995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY CORNELISON | ||||||||
| FirstName: | LAINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONTGOMERY | ||||||||
| OtherFirstName: | LAINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7190 CRESTWOOD BLVD | ||||||||
| Address2: | KAISER PERMANENTE FREDERICK MEDICAL CENTER | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217037314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405291700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101249806 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD040239 | DC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | D72798 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.