Healthcare Provider Details

I. General information

NPI: 1912443722
Provider Name (Legal Business Name): MAGNOLIA INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E SHILOH RD
CORINTH MS
38834-3724
US

IV. Provider business mailing address

2000 E SHILOH RD
CORINTH MS
38834-3724
US

V. Phone/Fax

Practice location:
  • Phone: 662-293-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RONNY HUMES
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 662-293-7664