MEDICARE: MAGNOLIA FOOT CLINIC LLC

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	213ES0103X	Foot & Ankle Surgery Podiatrist	80193	MS

General Provider Information

NPI Number	:	1699070326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA FOOT CLINIC LLC

Provider Business Mailing Address
First Line	:	2310 4TH ST
Second Line	:	SUITE A
City	:	MERIDIAN
State	:	MS
Zip	:	39301-5819
Country	:	US
Telephone Number	:	601-286-3745
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 4TH ST
Second Line	:	SUITE A
City	:	MERIDIAN
State	:	MS
Zip	:	39301-5819
Country	:	US
Telephone Number	:	601-286-3745
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT SETH CROCKETT
Credential	:	DPM
Telephone Number	:	601-934-8921

Provider Enumeration Date	:	01/11/2011
Last Update Date	:	07/25/2012

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