Provider Demographics
NPI:1235107913
Name:MONTGOMERY, CHARLES II (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:MONTGOMERY
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 20TH ST
Mailing Address - Street 2:SUITE 606
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1809
Mailing Address - Country:US
Mailing Address - Phone:865-546-8040
Mailing Address - Fax:
Practice Address - Street 1:501 20TH ST
Practice Address - Street 2:SUITE 606
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1809
Practice Address - Country:US
Practice Address - Phone:865-546-8040
Practice Address - Fax:865-541-2787
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26340207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN050083450OtherTRAVELERS MEDICARE
TN4020734OtherBLUE CROSS
TN3099461Medicaid
TN100021855OtherPHP TENNCARE
TN4020734OtherBLUECARE
TN4020734OtherBLUECARE
TNG25056Medicare UPIN