Healthcare Provider Details

I. General information

NPI: 1437192242
Provider Name (Legal Business Name): SHIRLEY MONTGOMERY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 E 75TH ST FIRST FLOOR
CHICAGO IL
60649-3603
US

IV. Provider business mailing address

1625 E 75TH ST FIRST FLOOR
CHICAGO IL
60649-3603
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-7500
  • Fax:
Mailing address:
  • Phone: 773-947-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-061800
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: