Healthcare Provider Details

I. General information

NPI: 1063439420
Provider Name (Legal Business Name): MONTGOMERY ELMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W 3RD ST
KIMBERLY WI
54136-1300
US

IV. Provider business mailing address

520 W 3RD ST
KIMBERLY WI
54136-1300
US

V. Phone/Fax

Practice location:
  • Phone: 920-788-7680
  • Fax: 920-788-7688
Mailing address:
  • Phone: 920-788-7680
  • Fax: 920-788-7688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28511
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: