Healthcare Provider Details

I. General information

NPI: 1083762819
Provider Name (Legal Business Name): STEFAN MONTGOMERY MD FAMILY & SPORTS MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 PELHAM CT
ORANGEBURG SC
29118-1400
US

IV. Provider business mailing address

PO BOX 1785
ORANGEBURG SC
29116-1785
US

V. Phone/Fax

Practice location:
  • Phone: 803-531-8500
  • Fax:
Mailing address:
  • Phone: 803-395-4499
  • Fax: 803-395-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: STEFAN L MONTGOMERY
Title or Position: OWNER
Credential: MD
Phone: 803-531-8500