Healthcare Provider Details

I. General information

NPI: 1669991337
Provider Name (Legal Business Name): MAGNOLIA FAMILY MEDICAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 09/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 PRATT DR STE 1A
CORINTH MS
38834-6026
US

IV. Provider business mailing address

401 ALCORN DR STE 2C
CORINTH MS
38834-9073
US

V. Phone/Fax

Practice location:
  • Phone: 662-286-0088
  • Fax: 662-286-0067
Mailing address:
  • Phone: 662-293-7266
  • Fax: 662-293-6255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RONNY HUMES
Title or Position: CEO
Credential:
Phone: 662-293-7664