Provider Demographics
NPI:1699070326
Name:MAGNOLIA FOOT CLINIC LLC
Entity type:Organization
Organization Name:MAGNOLIA FOOT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SETH
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-934-8921
Mailing Address - Street 1:2310 4TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-5819
Mailing Address - Country:US
Mailing Address - Phone:601-286-3745
Mailing Address - Fax:
Practice Address - Street 1:2310 4TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-5819
Practice Address - Country:US
Practice Address - Phone:601-286-3745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80193213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS6674440001Medicare NSC