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General NPI Number Information
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NPI Number | 1699787515
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Entity Type | Organization
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Legal Business Name | MAGNOLIA FAMILY MEDICINE, PLLC
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Dates
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Enumeration Date | 08/12/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 415 MARION AVE SUITE 399
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City | MCCOMB
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State | MS
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Zip | 39648-2709
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Country | US
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Telephone | 601-684-8800
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Fax | 601-914-2937
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Provider Business Mailing Address
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Address Line | 1074 BRANDON DR
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City | MCCOMB
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State | MS
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Zip | 39648-6130
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Country | US
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Telephone | 601-684-1633
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Fax | 601-914-2937
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Authorized Official
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Title or Position | OWNER
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Name | LARRY LEE MONTGOMERY
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Credential | M.D.
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Telephone | 601-684-8800
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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 | 16277
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License Number State | MS
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