Healthcare Provider Details

I. General information

NPI: 1134142284
Provider Name (Legal Business Name): MAGNOLIA SURGICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 ALCORN DRIVE 102
CORINTH MS
38834-9323
US

IV. Provider business mailing address

P.O. BOX 2040
CORINTH MS
38835-9302
US

V. Phone/Fax

Practice location:
  • Phone: 662-286-2522
  • Fax: 662-293-4288
Mailing address:
  • Phone: 662-286-2522
  • Fax: 662-293-4288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number05438
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HOWARD NELSON
Title or Position: VP PHYSICIAN SERVICES
Credential:
Phone: 662-293-7618