Provider Demographics
NPI:1588660674
Name:MAGNOLIA MEDICAL CENTER
Entity Type:Organization
Organization Name:MAGNOLIA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:228-872-5551
Mailing Address - Street 1:PO BOX 1797
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39566-1797
Mailing Address - Country:US
Mailing Address - Phone:228-872-5551
Mailing Address - Fax:
Practice Address - Street 1:3612 GROVELAND RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:228-872-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2007-07-10
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
MS09015939Medicaid