Provider Demographics
NPI:1124260211
Name:MONTGOMERY DERMATOLOGY, LLC
Entity type:Organization
Organization Name:MONTGOMERY DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERUM
Authorized Official - Middle Name:NASEEM
Authorized Official - Last Name:ILYAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-694-4851
Mailing Address - Street 1:491 ALLENDALE RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1426
Mailing Address - Country:US
Mailing Address - Phone:610-265-1166
Mailing Address - Fax:610-265-1186
Practice Address - Street 1:491 ALLENDALE RD
Practice Address - Street 2:SUITE 302
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-1426
Practice Address - Country:US
Practice Address - Phone:610-265-1166
Practice Address - Fax:610-265-1186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD424557207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty