Healthcare Provider Details

I. General information

NPI: 1043312747
Provider Name (Legal Business Name): EMILY A.P. MONTGOMERY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

IV. Provider business mailing address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

V. Phone/Fax

Practice location:
  • Phone: 304-347-1300
  • Fax: 304-347-1397
Mailing address:
  • Phone: 304-347-1300
  • Fax: 304-347-1397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19240
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number19240
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: