Healthcare Provider Details

I. General information

NPI: 1639497241
Provider Name (Legal Business Name): JEFFREY MONTGOMERY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY SLOT # 653
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

7419 OHIO ST APT 1B
LITTLE ROCK AR
72207-5066
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberE-7963
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: