=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699070326
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA FOOT CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2011
-----------------------------------------------------
Last Update Date | 07/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2310 4TH ST SUITE A
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39301-5819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-286-3745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2310 4TH ST SUITE A
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39301-5819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-286-3745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT SETH CROCKETT
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 601-934-8921
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 80193
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------