MEDICARE: MS. LACEY MONTGOMERY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant		IL

General Provider Information

NPI Number	:	1639166796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LACEY MONTGOMERY PA-C

Provider Business Mailing Address
First Line	:	5841 S MARYLAND AVE # MC4028
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-1447
Country	:	US
Telephone Number	:	773-834-7136
Fax Number	:

Provider Business Practice Location Address
First Line	:	5841 S MARYLAND AVE # MC4028
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-1447
Country	:	US
Telephone Number	:	773-834-7136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	08/21/2007

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