Healthcare Provider Details

I. General information

NPI: 1982009031
Provider Name (Legal Business Name): MAGNOLIA GENERAL AND VASCULAR SURGERY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 ALCORN DR STE 210
CORINTH MS
38834-9323
US

IV. Provider business mailing address

P.O BOX 2040
CORINTH MS
38835-2040
US

V. Phone/Fax

Practice location:
  • Phone: 662-284-9910
  • Fax: 662-284-9970
Mailing address:
  • Phone: 662-284-9910
  • Fax: 662-284-9970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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