Provider Demographics
NPI:1164293387
Name:MAGNOLIA PREMIER MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:MAGNOLIA PREMIER MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY MEDICINE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:DAMON
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C
Authorized Official - Phone:601-613-5681
Mailing Address - Street 1:4366 S SIWELL RD
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39212-6213
Mailing Address - Country:US
Mailing Address - Phone:601-613-5681
Mailing Address - Fax:601-372-3059
Practice Address - Street 1:1000 HIGHLAND COLONY PKWY STE 35203
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2073
Practice Address - Country:US
Practice Address - Phone:601-613-5682
Practice Address - Fax:601-372-3059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty