Healthcare Provider Details

I. General information

NPI: 1649258922
Provider Name (Legal Business Name): MARY T MONTAGUE CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY T SOPKO

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-1878
  • Fax: 216-636-0455
Mailing address:
  • Phone: 216-444-1878
  • Fax: 216-636-0455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberNS08605
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: