MEDICARE: STEFAN L MONTGOMERY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician	27277	SC
2	207Q00000X	Family Medicine Physician	27277	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	AA05373365	OTHER	SC	MEDICARE PIN
3	P01556670	OTHER	SC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437135944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEFAN L MONTGOMERY MD

Provider Business Mailing Address
First Line	:	PO BOX 743070
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3070
Country	:	US
Telephone Number	:	864-560-4304
Fax Number	:	864-560-4413

Provider Business Practice Location Address
First Line	:	853 N CHURCH ST
Second Line	:	SUITE 510
City	:	SPARTANBURG
State	:	SC
Zip	:	29303-3098
Country	:	US
Telephone Number	:	864-560-6193
Fax Number	:	864-560-1510

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	02/01/2021

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Directions to “ STEFAN L MONTGOMERY MD” Practice Location

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