Healthcare Provider Details

I. General information

NPI: 1679054696
Provider Name (Legal Business Name): TRAVIS MONTGOMERY RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST STE 308
OAK LAWN IL
60453-2660
US

IV. Provider business mailing address

9500 BORMET DR STE 204
MOKENA IL
60448-8399
US

V. Phone/Fax

Practice location:
  • Phone: 708-346-4040
  • Fax: 708-346-3287
Mailing address:
  • Phone: 708-346-4044
  • Fax: 708-346-3287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238000654
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number041472495
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: