NPIMap

Individual provider Active NPI

Mandrill Deangelo Montgomery, CRNA

  • Certified Registered Nurse Anesthetist
  • Greenville, SC
National Provider Identifier
1255505665
Registry record updated Mar 19, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Certified Registered Nurse AnesthetistTaxonomy code 367500000X
License
101035 Issued in SC
Practice address
701 Grove Rd
Greenville, SC 29605-5611
Phone
(864) 454-7111
Fax
(864) 455-6441
NPI assigned
Apr 16, 2008
Last updated
Mar 19, 2014By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 19, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Certified Registered Nurse Anesthetist 367500000X 101035 SC Primary

Addresses

Primary practice location

701 Grove Rd
Greenville, SC 29605-5611

Mailing address

1 Independence PT
Suite 212
Greenville, SC 29615-4545
Phone (864) 797-6307

Other identifiers 1

IdentifierTypeStateIssuer
57-6007863OtherSCTAX ID

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080717000004 SC Practitioner - Certified Registered Nurse Anesthetist (Crna) 5991878423 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Certified Registered Nurse Anesthetist (Crna)
Education
Other, 2008
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Spartanburg Medical CenterGroup PAC ID 3072425297, 1,060 clinicians

Practice addresses (Care Compare)

101 E Wood St
Spartanburg, SC 29303-3040
Phone (864) 560-1915

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
94.7 of 100Reported as apm
Quality
89.4
Promoting interoperability
100
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Certified Registered Nurse

State licenses

LicenseStateTypeSpecialty
3620SCMDSurgical Physician Assistant
101035SCMDCertified Registered Nurse Anesthetist

Practice roles

OrganizationSpecialtyStatusNew patients
Spartanburg Medical Center Current Accepting new patients
Spartanburg Medical Center Nurse Anesthetist, Certified Registered CurrentSince Mar 11, 2019 Accepting new patients
Spartanburg Medical Center CurrentSince Mar 11, 2019 Accepting new patients
Pelham Medical Center CurrentSince Jan 1, 2023 Accepting new patients
Pelham Medical Center Nurse Anesthetist, Certified Registered CurrentSince Jan 1, 2023 Accepting new patients
Greenville Health System Past Accepting new patients
Greenville Anesthesiology, PA Past Accepting new patients

Locations

22725 US Highway 76
Clinton, SC 29325
Phone (864) 833-9100

250 Westmoreland Rd
Greer, SC 29651
Phone (864) 530-2108

101 E Wood St
Spartanburg, SC 29303
Phone (864) 560-1915

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1208304000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1395187200000",
    "number": "1255505665",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 INDEPENDENCE PT",
            "address_2": "SUITE 212",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296154545",
            "telephone_number": "864-797-6307",
            "fax_number": "864-797-6198"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "701 GROVE RD",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296055611",
            "telephone_number": "864-454-7111",
            "fax_number": "864-455-6441"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MONTGOMERY",
        "first_name": "MANDRILL",
        "middle_name": "DEANGELO",
        "credential": "CRNA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-04-16",
        "last_updated": "2014-03-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "SC",
            "license": "101035",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TAX ID",
            "identifier": "57-6007863",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Greenville, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 19, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.