Healthcare Provider Details

I. General information

NPI: 1932425162
Provider Name (Legal Business Name): SAMUEL MONTGOMERY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-3658
  • Fax:
Mailing address:
  • Phone: 704-355-3658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number164516
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: