Provider Demographics
NPI:1881959401
Name:MAGNOLIA SPECIALTY CLINIC
Entity type:Organization
Organization Name:MAGNOLIA SPECIALTY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PHYSICIAN 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:662-665-8041
Mailing Address - Fax:662-665-8049
Practice Address - Street 1:3704 HWY. 72 WEST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-8556
Practice Address - Country:US
Practice Address - Phone:662-665-8041
Practice Address - Fax:662-665-8049
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-10
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty