Provider Demographics
NPI:1467567990
Name:MAGNOLIA INTERNAL MEDICAL CLINIC
Entity Type:Organization
Organization Name:MAGNOLIA INTERNAL MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:M,D,
Authorized Official - Phone:601-933-9696
Mailing Address - Street 1:PO BOX 321411
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-1411
Mailing Address - Country:US
Mailing Address - Phone:601-933-9696
Mailing Address - Fax:
Practice Address - Street 1:5 RIVER BEND PL
Practice Address - Street 2:SUITE C
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7618
Practice Address - Country:US
Practice Address - Phone:601-933-9696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06923312Medicaid
MSC03580Medicare PIN