Provider Demographics
NPI:1629516968
Name:MAGNOLIA SURGICAL CLINIC
Entity Type:Organization
Organization Name:MAGNOLIA SURGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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 1:703 ALCORN DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9302
Mailing Address - Country:US
Mailing Address - Phone:662-286-2522
Mailing Address - Fax:662-293-4288
Practice Address - Street 1:703 ALCORN DR
Practice Address - Street 2:SUITE 102
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9302
Practice Address - Country:US
Practice Address - Phone:662-286-2522
Practice Address - Fax:662-293-4288
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty