Healthcare Provider Details

I. General information

NPI: 1801818059
Provider Name (Legal Business Name): DR. JANICE LYNN MONTAGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 LAFAYETTE AVENUE SUITE 290
SUFFERN NY
10901
US

IV. Provider business mailing address

257 LAFAYETTE AVENUE SUITE 290
SUFFERN NY
10901
US

V. Phone/Fax

Practice location:
  • Phone: 845-369-3550
  • Fax: 845-369-3552
Mailing address:
  • Phone: 845-369-3550
  • Fax: 845-369-3552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number194024
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01600522046
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: