Provider Demographics
NPI:1366463549
Name:MAGNOLIA PROFESSIONAL ASSOCIATES
Entity Type:Organization
Organization Name:MAGNOLIA PROFESSIONAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR PHYSICIAN SERVIC
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-293-7678
Mailing Address - Street 1:P.O. BOX 2040
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-2040
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 2:109
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05323894Medicaid
MS05323894Medicaid