Healthcare Provider Details

I. General information

NPI: 1144491580
Provider Name (Legal Business Name): MAGNOLIA WOMAN'S CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 LAKELAND DR SUITE 43
JACKSON MS
39216-4635
US

IV. Provider business mailing address

970 LAKELAND DR SUITE 43
JACKSON MS
39216-4635
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-8201
  • Fax:
Mailing address:
  • Phone: 601-200-8201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number11096
License Number StateMS

VIII. Authorized Official

Name: WALTER RAY WOLFE
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 601-200-8201