Provider Demographics
NPI:1053780007
Name:MONTGOMERY, MICHAEL ALBERT (RN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALBERT
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-1123
Mailing Address - Country:US
Mailing Address - Phone:315-472-1212
Mailing Address - Fax:
Practice Address - Street 1:319 E WATER ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-1123
Practice Address - Country:US
Practice Address - Phone:315-472-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY524634163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse