Provider Demographics
NPI:1841645470
Name:MAGNOLIA DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:MAGNOLIA DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIN
Authorized Official - Middle Name:COLLIER
Authorized Official - Last Name:HURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-910-3004
Mailing Address - Street 1:815 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5252
Mailing Address - Country:US
Mailing Address - Phone:601-910-3004
Mailing Address - Fax:
Practice Address - Street 1:815 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5252
Practice Address - Country:US
Practice Address - Phone:601-910-3004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21939207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty