=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689316986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTANA HEMEONCOLOGY LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2022
-----------------------------------------------------
Last Update Date | 04/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 GOSFORD ROAD #106
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-301-7494
-----------------------------------------------------
Fax | 661-885-6088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 GOSFORD ROAD #106
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | WILBUR N. MONTANA
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 661-301-7494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------