Provider Demographics
NPI:1225320708
Name:PSP MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:PSP MEDICAL CLINIC LLC
Other - Org Name:MAGNOLIA MEDICAL CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:PARVESH
Authorized Official - Middle Name:K
Authorized Official - Last Name:GOEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-746-3555
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0607
Mailing Address - Country:US
Mailing Address - Phone:662-746-3555
Mailing Address - Fax:601-859-9966
Practice Address - Street 1:1171 HART ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4805
Practice Address - Country:US
Practice Address - Phone:601-859-9888
Practice Address - Fax:601-859-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15405261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06572715Medicaid
MS07228530Medicaid
MS00118231Medicaid
MS02679823Medicaid
MS09238061Medicaid