Provider Demographics
NPI:1225157258
Name:MAGEE BENEVOLENT ASSOCIATION
Entity Type:Organization
Organization Name:MAGEE BENEVOLENT ASSOCIATION
Other - Org Name:THE MEDICAL PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY NURSE PRACTIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCRUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-782-9797
Mailing Address - Street 1:234 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:MS
Mailing Address - Zip Code:39153-6016
Mailing Address - Country:US
Mailing Address - Phone:601-782-9797
Mailing Address - Fax:601-782-9790
Practice Address - Street 1:234 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153-6016
Practice Address - Country:US
Practice Address - Phone:601-782-9797
Practice Address - Fax:601-782-9790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR764114363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07585555Medicaid
MS00117436Medicaid
MS07585555Medicaid