Provider Demographics
NPI:1134142284
Name:MAGNOLIA SURGICAL GROUP
Entity Type:Organization
Organization Name:MAGNOLIA SURGICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PHYSICIAN SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-293-7618
Mailing Address - Street 1:P.O. BOX 2040
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-9302
Mailing Address - Country:US
Mailing Address - Phone:662-286-2522
Mailing Address - Fax:662-293-4288
Practice Address - Street 1:703 ALCORN DRIVE
Practice Address - Street 2:102
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9323
Practice Address - Country:US
Practice Address - Phone:662-286-2522
Practice Address - Fax:662-293-4288
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-26
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05438208600000X
208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06486235Medicaid
MS06486235Medicaid