Provider Demographics
NPI:1235429648
Name:MONTGOMERY FAMILY CLINIC
Entity Type:Organization
Organization Name:MONTGOMERY FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, RN, FNP-DC
Authorized Official - Phone:601-790-9098
Mailing Address - Street 1:122 WEISENBERGER RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7993
Mailing Address - Country:US
Mailing Address - Phone:601-790-9098
Mailing Address - Fax:601-790-9098
Practice Address - Street 1:122 WEISENBERGER RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7993
Practice Address - Country:US
Practice Address - Phone:601-790-9098
Practice Address - Fax:601-790-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR524174261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care