Healthcare Provider Details

I. General information

NPI: 1174286579
Provider Name (Legal Business Name): SPENCER MONTGOMERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2365 E GALA ST STE 1
MERIDIAN ID
83642-4881
US

IV. Provider business mailing address

2365 E GALA ST STE 1
MERIDIAN ID
83642-4881
US

V. Phone/Fax

Practice location:
  • Phone: 208-391-5811
  • Fax: 208-391-5807
Mailing address:
  • Phone: 208-391-5811
  • Fax: 208-391-5807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number9171794
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: