Provider Demographics
NPI:1396775797
Name:MAGNOLIA PEDIATRIC CLINIC, INC.
Entity type:Organization
Organization Name:MAGNOLIA PEDIATRIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-234-5171
Mailing Address - Street 1:306 E MCNEIL
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2927
Mailing Address - Country:US
Mailing Address - Phone:870-234-5171
Mailing Address - Fax:870-234-0507
Practice Address - Street 1:306 E MCNEIL
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2927
Practice Address - Country:US
Practice Address - Phone:870-234-5171
Practice Address - Fax:870-234-0507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2147208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140579002Medicaid