Provider Demographics
NPI:1699787515
Name:MAGNOLIA FAMILY MEDICINE, PLLC
Entity type:Organization
Organization Name:MAGNOLIA FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-684-8800
Mailing Address - Street 1:1074 BRANDON DR
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-6130
Mailing Address - Country:US
Mailing Address - Phone:601-684-1633
Mailing Address - Fax:601-914-2937
Practice Address - Street 1:415 MARION AVE
Practice Address - Street 2:SUITE 399
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2709
Practice Address - Country:US
Practice Address - Phone:601-684-8800
Practice Address - Fax:601-914-2937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120513Medicaid
MS16277OtherSTATE MEDICAL LICENSE
MS16277OtherSTATE MEDICAL LICENSE
MS00120513Medicaid
MS080004126Medicare ID - Type Unspecified