| Name: | Montgomery Trauma Associates, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Dissolved |
| Date of registration: | 24 Jun 2005 (19 years ago) (Companies founded in June 2005) |
| Date of dissolution: | 31 Dec 2008 |
| Entity Number: | 000-465-804 |
| Register Number: | 000465804 |
| Place of Formation: | Russell County |
| Principal Address: | MONTGOMERY, AL |
| Registered Office Street Address: | 2055 EAST SOUTH BOULEVARD STE 603MONTGOMERY, AL 36116-2012 |
Activities
PROVIDE MEDICAL SERVICES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1902964570 | 2006-12-05 | 2008-05-02 | 2055 E SOUTH BLVD, SUITE 601, MONTGOMERY, AL, 361162001, US | 2055 E SOUTH BLVD, SUITE 601, MONTGOMERY, AL, 361162001, US | |||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||
| Phone | +1 334-281-9000 |
| Fax | 3342818262 |
Authorized person
| Name | TAMMY G MILLER |
| Role | BILLING MANAGER |
| Phone | 3346137076 |
Taxonomy
| Taxonomy Code | 305R00000X - Preferred Provider Organization |
| State | AL |
| Is Primary | Yes |
| Taxonomy Code | 305R00000X - Preferred Provider Organization |
| License Number | 26765 |
| State | AL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BCBS AL VERMILLION |
| Number | 51001703 |
| State | AL |
| Issuer | VERMILLION NPI |
| Number | 1659454254 |
| State | AL |
| Issuer | MEDICAID |
| Number | 529926030 |
| State | AL |
| Name | Role |
|---|---|
| DALY, DANIEL M | Agent |
| Name | Role |
|---|---|
| DALY, DANIEL M | Member |
| HARRIS, ROBERT B | Member |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
