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General NPI Number Information
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NPI Number | 1518940881
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Entity Type | Organization
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Legal Business Name | ANTHONY WAYNE FAMILY PRACTICE INC
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Dates
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Enumeration Date | 11/21/2005
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Last Update Date | 07/29/2013
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Provider Practice Location Address
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Address Line | 5757 MONCLOVA RD STE 24
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City | MAUMEE
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State | OH
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Zip | 43537
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Country | US
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Telephone | 419-897-2290
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Fax | 419-897-2290
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Provider Business Mailing Address
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Address Line | 5757 MONCLOVA RD STE 24
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City | MAUMEE
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State | OH
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Zip | 43537
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Country | US
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Telephone | 419-897-2270
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Fax | 419-897-2290
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRUCE A MONTGOMERY
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Credential | DO
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Telephone | 419-897-2270
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 34004231M
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License Number State | OH
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