Healthcare Provider Details

I. General information

NPI: 1750547113
Provider Name (Legal Business Name): SUSAN KATHLEEN MONTGOMERY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21632 HIGHWAY 99
EDMONDS WA
98026-8032
US

IV. Provider business mailing address

21632 HIGHWAY 99
EDMONDS WA
98026-8032
US

V. Phone/Fax

Practice location:
  • Phone: 425-673-8300
  • Fax:
Mailing address:
  • Phone: 425-673-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD 60222813
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: