Healthcare Provider Details

I. General information

NPI: 1225851074
Provider Name (Legal Business Name): JERRY MONTGOMERY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 QUEENS PLZ N
LONG ISLAND CITY NY
11101-4172
US

IV. Provider business mailing address

107 LOGAN AVE
STATEN ISLAND NY
10301-4259
US

V. Phone/Fax

Practice location:
  • Phone: 718-391-8300
  • Fax:
Mailing address:
  • Phone: 347-328-7794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number876366
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: