Provider Demographics
NPI:1033226436
Name:MAGNOLIA CLINIC, INC.
Entity Type:Organization
Organization Name:MAGNOLIA CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-783-0374
Mailing Address - Street 1:111 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:MS
Mailing Address - Zip Code:39652-2825
Mailing Address - Country:US
Mailing Address - Phone:601-783-0374
Mailing Address - Fax:601-783-5126
Practice Address - Street 1:111 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:MS
Practice Address - Zip Code:39652-2825
Practice Address - Country:US
Practice Address - Phone:601-783-0374
Practice Address - Fax:601-783-5126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9013142Medicaid
MSCM1263Medicare ID - Type UnspecifiedRR MEDICARE
MS9013142Medicaid