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General NPI Number Information
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NPI Number | 1841645470
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Entity Type | Organization
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Legal Business Name | MAGNOLIA DERMATOLOGY, PLLC
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Dates
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Enumeration Date | 05/02/2016
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Last Update Date | 05/02/2016
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Provider Practice Location Address
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Address Line | 815 HIGHWAY 80 E
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City | CLINTON
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State | MS
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Zip | 39056-5252
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Country | US
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Telephone | 601-910-3004
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Fax |
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Provider Business Mailing Address
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Address Line | 815 HIGHWAY 80 E
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City | CLINTON
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State | MS
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Zip | 39056-5252
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Country | US
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Telephone | 601-910-3004
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Fax |
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | CHRISTIN COLLIER HURT
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Credential | MD
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Telephone | 601-910-3004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 21939
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License Number State | MS
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