Provider Demographics
NPI:1912443722
Name:MAGNOLIA INTERNAL MEDICINE
Entity Type:Organization
Organization Name:MAGNOLIA INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
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 1:2000 E SHILOH RD
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-3724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 E SHILOH RD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-3724
Practice Address - Country:US
Practice Address - Phone:662-293-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty