Healthcare Provider Details

I. General information

NPI: 1003278532
Provider Name (Legal Business Name): MEGAN MARIE MONTAGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1137 INDEPENDENCE DR
WEST PLAINS MO
65775-4221
US

IV. Provider business mailing address

571 S FLOYD ST SUITE 412
LOUISVILLE KY
40202-3818
US

V. Phone/Fax

Practice location:
  • Phone: 417-255-8464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019026178
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: