MEDICARE: MAGNOLIA ORTHOPAEDICS & SPORTS MEDICINE, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063433233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA ORTHOPAEDICS & SPORTS MEDICINE, P.A.

Provider Business Mailing Address
First Line	:	611 ALCORN DR
Second Line	:	SUITE 100
City	:	CORINTH
State	:	MS
Zip	:	38834-9321
Country	:	US
Telephone Number	:	662-286-6369
Fax Number	:	662-286-2768

Provider Business Practice Location Address
First Line	:	611 ALCORN DR
Second Line	:	SUITE 100
City	:	CORINTH
State	:	MS
Zip	:	38834-9321
Country	:	US
Telephone Number	:	662-286-6369
Fax Number	:	662-286-2768

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	CHARLIE GOOCH
Credential	:
Telephone Number	:	662-286-6369

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	08/15/2013

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Directions to “MAGNOLIA ORTHOPAEDICS & SPORTS MEDICINE, P.A. ” Practice Location

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