Healthcare Provider Details

I. General information

NPI: 1518941731
Provider Name (Legal Business Name): MAGNOLIA GASTROENTEROLOGY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 CORDER DRIVE MAGNOLIA GASTROENTEROLOGY CLINIC, LLC
CORINTH MS
38834
US

IV. Provider business mailing address

PO BOX 600
CORINTH MS
38835-0600
US

V. Phone/Fax

Practice location:
  • Phone: 662-284-9902
  • Fax: 662-284-9904
Mailing address:
  • Phone: 662-284-9902
  • Fax: 662-284-9904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FREDRICK ALVIN CORDER
Title or Position: OWNER/PHYSICIAN/MEDICAL DIRECTOR
Credential: M.D.
Phone: 662-284-9902