1518941731 NPI number — MAGNOLIA GASTROENTEROLOGY CLINIC, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518941731 NPI number — MAGNOLIA GASTROENTEROLOGY CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA GASTROENTEROLOGY CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518941731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORINTH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38835-0600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-284-9902
Provider Business Mailing Address Fax Number:
662-284-9904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3050 CORDER DRIVE
Provider Second Line Business Practice Location Address:
MAGNOLIA GASTROENTEROLOGY CLINIC, LLC
Provider Business Practice Location Address City Name:
CORINTH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-284-9902
Provider Business Practice Location Address Fax Number:
662-284-9904
Provider Enumeration Date:
12/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CORDER
Authorized Official First Name:
FREDRICK
Authorized Official Middle Name:
ALVIN
Authorized Official Title or Position:
OWNER/PHYSICIAN/MEDICAL DIRECTOR
Authorized Official Telephone Number:
662-284-9902

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09016046 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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