Healthcare Provider Details

I. General information

NPI: 1881674802
Provider Name (Legal Business Name): MICHAEL K MONTELLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 S MAIN AVE
SCRANTON PA
18504-2146
US

IV. Provider business mailing address

743 S MAIN AVE SUITE 6
SCRANTON PA
18504-2146
US

V. Phone/Fax

Practice location:
  • Phone: 570-969-0693
  • Fax: 570-341-8879
Mailing address:
  • Phone: 570-969-9693
  • Fax: 570-341-8879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD039391E
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier001161982
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: