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General NPI Number Information
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NPI Number | 1396775797
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Entity Type | Organization
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Legal Business Name | MAGNOLIA PEDIATRIC CLINIC, INC.
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Dates
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Enumeration Date | 07/03/2006
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Last Update Date | 02/20/2012
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Provider Practice Location Address
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Address Line | 306 E MCNEIL
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City | MAGNOLIA
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State | AR
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Zip | 71753-2927
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Country | US
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Telephone | 870-234-5171
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Fax | 870-234-0507
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Provider Business Mailing Address
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Address Line | 306 E MCNEIL
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City | MAGNOLIA
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State | AR
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Zip | 71753-2927
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Country | US
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Telephone | 870-234-5171
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Fax | 870-234-0507
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | AMY CROSS
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Credential | M.D.
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Telephone | 870-234-5171
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | E2147
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License Number State | AR
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