Healthcare Provider Details

I. General information

NPI: 1083609747
Provider Name (Legal Business Name): BENJAMIN E. MONTGOMERY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 ATLANTA ST STE 100
SPRINGFIELD IL
62707-8801
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8801
  • Fax: 217-545-4444
Mailing address:
  • Phone: 217-545-8000
  • Fax: 844-470-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-109933
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: