Provider Demographics
NPI:1144491580
Name:MAGNOLIA WOMAN'S CLINIC, P.A.
Entity type:Organization
Organization Name:MAGNOLIA WOMAN'S CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-200-8201
Mailing Address - Street 1:970 LAKELAND DR
Mailing Address - Street 2:SUITE 43
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4635
Mailing Address - Country:US
Mailing Address - Phone:601-200-8201
Mailing Address - Fax:
Practice Address - Street 1:970 LAKELAND DR
Practice Address - Street 2:SUITE 43
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4635
Practice Address - Country:US
Practice Address - Phone:601-200-8201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11096207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00131201Medicaid
4224712OtherAETNA
MS7430106OtherUNITED HEALTH CARE
MS428940305AOtherBLUE CROSS BLUE SHEILD