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General NPI Number Information
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NPI Number | 1164293387
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Entity Type | Organization
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Legal Business Name | MAGNOLIA PREMIER MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 01/16/2024
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Last Update Date | 01/16/2024
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Provider Practice Location Address
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Address Line | 1000 HIGHLAND COLONY PKWY STE 35203
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City | RIDGELAND
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State | MS
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Zip | 39157-2073
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Country | US
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Telephone | 601-613-5682
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Fax | 601-372-3059
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Provider Business Mailing Address
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Address Line | 4366 S SIWELL RD
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City | BYRAM
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State | MS
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Zip | 39212-6213
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Country | US
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Telephone | 601-613-5681
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Fax | 601-372-3059
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Authorized Official
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Title or Position | FAMILY MEDICINE PROVIDER
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Name | CRAIG DAMON HENRY
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Credential | APRN, FNP-C
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Telephone | 601-613-5681
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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