Healthcare Provider Details

I. General information

NPI: 1851680938
Provider Name (Legal Business Name): KELLY PASCUAL MONTGOMERY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CHARLIE MORRIS RD
COLBERT GA
30628
US

IV. Provider business mailing address

11 CHARLIE MORRIS RD
COLBERT GA
30628-2445
US

V. Phone/Fax

Practice location:
  • Phone: 706-788-2127
  • Fax: 706-788-2815
Mailing address:
  • Phone: 706-788-3234
  • Fax: 706-788-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number081011
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: