Healthcare Provider Details

I. General information

NPI: 1144807124
Provider Name (Legal Business Name): KYLE MEDER MONTGOMERY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 PROVIDENCE DR STE 207
ANCHORAGE AK
99508-4620
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 907-561-0005
  • Fax: 907-563-9140
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number252520
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: