Healthcare Provider Details

I. General information

NPI: 1922625672
Provider Name (Legal Business Name): TANYA MONTGOMERY NEE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 WEST POLK STREET, NEONATAL AND PERINATAL DEPARTMENT
CHICAGO IL
60612
US

IV. Provider business mailing address

1950 W POLK ST
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4044
  • Fax:
Mailing address:
  • Phone: 312-864-0393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.076792
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: