Provider Demographics
NPI:1437685278
Name:MAGNOLIA PRIMARY CARE
Entity Type:Organization
Organization Name:MAGNOLIA PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RONNY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HUMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-293-7664
Mailing Address - Street 1:401 ALCORN DR STE 2C
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9073
Mailing Address - Country:US
Mailing Address - Phone:662-293-7266
Mailing Address - Fax:662-293-6255
Practice Address - Street 1:202 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9701
Practice Address - Country:US
Practice Address - Phone:662-287-4481
Practice Address - Fax:662-287-4368
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-11
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05252561Medicaid