=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497865893
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTGOMERY OTOLARYNGOLOGY LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 04/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1722 PINE ST SUITE 804
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36106-1103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-834-7221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1722 PINE ST SUITE 804
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36106-1103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-834-7221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. RODGER EGELAND
-----------------------------------------------------
Credential | MPH
-----------------------------------------------------
Telephone | 334-834-7221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------