=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871034488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTGOMERY ORTHOPEDIC CARE SPECIALISTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2017
-----------------------------------------------------
Last Update Date | 06/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 MEDICAL CENTER BLVD
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-2808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-251-1132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13737 NOEL RD 1600
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75240-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-838-2371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | KATHLEEN KONDAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-251-1132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0127X
-----------------------------------------------------
Taxonomy Name | Trauma Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------