Healthcare Provider Details

I. General information

NPI: 1902915960
Provider Name (Legal Business Name): GREGORY S MONTGOMERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR ROC 4270
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 1026
INDIANAPOLIS IN
46206-1026
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-7208
  • Fax: 317-274-3442
Mailing address:
  • Phone: 317-274-1201
  • Fax: 317-278-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number01060650
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: