Provider Demographics
NPI:1881132124
Name:MAGNOLIA EAR NOSE & THROAT
Entity type:Organization
Organization Name:MAGNOLIA EAR NOSE & THROAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-293-7664
Mailing Address - Street 1:401 ALCORN DR STE 2C
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9073
Mailing Address - Country:US
Mailing Address - Phone:662-293-7266
Mailing Address - Fax:662-293-6255
Practice Address - Street 1:401 ALCORN DR
Practice Address - Street 2:SUITE 2 D
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834
Practice Address - Country:US
Practice Address - Phone:662-293-1565
Practice Address - Fax:662-293-4204
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:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07633259Medicaid
MS583312OtherMS MEDICARE