Provider Demographics
NPI:1689683351
Name:MAGNOLIA MEDICAL, LLC
Entity Type:Organization
Organization Name:MAGNOLIA MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-763-1314
Mailing Address - Street 1:304 HIGHLAND BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120
Mailing Address - Country:US
Mailing Address - Phone:601-442-6493
Mailing Address - Fax:601-445-0999
Practice Address - Street 1:5412 DIJON DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4315
Practice Address - Country:US
Practice Address - Phone:225-615-8693
Practice Address - Fax:225-448-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05828/11.1332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4726240001Medicare ID - Type Unspecified
MS09878226Medicaid