Provider Demographics
NPI:1215144282
Name:MONTGOMERY FAMILY HEALTH CENTER INC
Entity type:Organization
Organization Name:MONTGOMERY FAMILY HEALTH CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:731-376-2804
Mailing Address - Street 1:727 S, MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:TN
Mailing Address - Zip Code:38052
Mailing Address - Country:US
Mailing Address - Phone:731-376-2804
Mailing Address - Fax:731-376-2806
Practice Address - Street 1:727 S, MAIN STREET
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:TN
Practice Address - Zip Code:38052
Practice Address - Country:US
Practice Address - Phone:731-376-2804
Practice Address - Fax:731-376-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000005776363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3728789Medicaid
TN3728789Medicare ID - Type Unspecified
TN3728789Medicaid