MEDICARE: KEITH MONTGOMERY MHPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1538523196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH MONTGOMERY MHPP

Provider Business Mailing Address
First Line	:	703 CALVIN AVERY DR
Second Line	:	SUITE A
City	:	WEST MEMPHIS
State	:	AR
Zip	:	72301-6501
Country	:	US
Telephone Number	:	870-732-1878
Fax Number	:	870-702-7111

Provider Business Practice Location Address
First Line	:	1718 LINDAUER RD
Second Line	:
City	:	FORREST CITY
State	:	AR
Zip	:	72335-2523
Country	:	US
Telephone Number	:	870-633-0511
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2016
Last Update Date	:	04/11/2016

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