Provider Demographics
NPI:1245581370
Name:PSP MEDICAL CLINIC
Entity Type:Organization
Organization Name:PSP MEDICAL CLINIC
Other - Org Name:MAGNOLIA MEDICAL CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
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:601-707-5621
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046
Mailing Address - Country:US
Mailing Address - Phone:601-859-9888
Mailing Address - Fax:601-859-9966
Practice Address - Street 1:1082A GLUCKSTADT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7243
Practice Address - Country:US
Practice Address - Phone:601-707-5621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS25D1087086OtherCLIA