Healthcare Provider Details

I. General information

NPI: 1437685278
Provider Name (Legal Business Name): MAGNOLIA PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 ALCORN DR
CORINTH MS
38834-9701
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 662-287-4481
  • Fax: 662-287-4368
Mailing address:
  • Phone: 662-293-7266
  • Fax: 662-293-6255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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