Provider Demographics
NPI:1982009031
Name:MAGNOLIA GENERAL AND VASCULAR SURGERY CLINIC
Entity Type:Organization
Organization Name:MAGNOLIA GENERAL AND VASCULAR SURGERY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PHYSAICIAN SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-293-7618
Mailing Address - Street 1:P.O BOX 2040
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-2040
Mailing Address - Country:US
Mailing Address - Phone:662-284-9910
Mailing Address - Fax:662-284-9970
Practice Address - Street 1:611 ALCORN DR STE 210
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9323
Practice Address - Country:US
Practice Address - Phone:662-284-9910
Practice Address - Fax:662-284-9970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty