Provider Demographics
NPI:1518941731
Name:MAGNOLIA GASTROENTEROLOGY CLINIC, LLC
Entity Type:Organization
Organization Name:MAGNOLIA GASTROENTEROLOGY CLINIC, LLC
Other - Org Name:CORINTH GASTROENTEROLOGY CLINIC, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHYSICIAN/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:CORDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-284-9902
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-0600
Mailing Address - Country:US
Mailing Address - Phone:662-284-9902
Mailing Address - Fax:662-284-9904
Practice Address - Street 1:3050 CORDER DRIVE
Practice Address - Street 2:MAGNOLIA GASTROENTEROLOGY CLINIC, LLC
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834
Practice Address - Country:US
Practice Address - Phone:662-284-9902
Practice Address - Fax:662-284-9904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016046Medicaid
MS09016046Medicaid