Provider Demographics
NPI:1558587568
Name:ROME SHERROD II
Entity Type:Organization
Organization Name:ROME SHERROD II
Other - Org Name:TRI-STATE HEALTHCARE FOR WOMEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:622-342-1005
Mailing Address - Street 1:835 BRANDYWINE DRIVE
Mailing Address - Street 2:#102
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2424
Mailing Address - Country:US
Mailing Address - Phone:662-342-1005
Mailing Address - Fax:662-342-0280
Practice Address - Street 1:835 BRANDYWINE DR
Practice Address - Street 2:#102
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2434
Practice Address - Country:US
Practice Address - Phone:662-342-1005
Practice Address - Fax:662-342-0280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS9374261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS160000623Medicare PIN
TNB59327Medicare UPIN