NPIMap

Organization Active NPI

Magnolia Orthopaedics & Sports Medicine, P.a.

  • Sports Medicine (Orthopaedic Surgery) Physician
  • Corinth, MS
National Provider Identifier
1063433233
Registry record updated Aug 15, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Sports Medicine (Orthopaedic Surgery) PhysicianTaxonomy code 207XX0005X
Legal business name
MAGNOLIA ORTHOPAEDICS & SPORTS MEDICINE, P.A.
Practice address
611 Alcorn Dr
Suite 100
Corinth, MS 38834-9321
Phone
(662) 286-6369
Fax
(662) 286-2768
NPI assigned
Jul 22, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 15, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Charlie Gooch
Title
Office Manager
Phone
(662) 286-6369

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Sports Medicine (Orthopaedic Surgery) PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207XX0005X Primary

Addresses

Primary practice location

611 Alcorn Dr
Suite 100
Corinth, MS 38834-9321

Mailing address

611 Alcorn Dr
Suite 100
Corinth, MS 38834-9321
Phone (662) 286-6369

Other identifiers 1

IdentifierTypeStateIssuer
09013928MedicaidMS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090818000406 MS Part B Supplier - Clinic/Group Practice 5395899850 Receives reassigned benefits from 7 practitioners
Practice locations: Corinth, MS
O20100930045638 MS DME Supplier - Physician - Orthopedic/Orthopedic Surgery 5395899850 Practice locations: Corinth, MS

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153526400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1376524800000",
    "number": "1063433233",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "611 ALCORN DR",
            "address_2": "SUITE 100",
            "city": "CORINTH",
            "state": "MS",
            "postal_code": "388349321",
            "telephone_number": "662-286-6369",
            "fax_number": "662-286-2768"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "611 ALCORN DR",
            "address_2": "SUITE 100",
            "city": "CORINTH",
            "state": "MS",
            "postal_code": "388349321",
            "telephone_number": "662-286-6369",
            "fax_number": "662-286-2768"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAGNOLIA ORTHOPAEDICS & SPORTS MEDICINE, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-22",
        "last_updated": "2013-08-15",
        "status": "A",
        "authorized_official_last_name": "GOOCH",
        "authorized_official_first_name": "CHARLIE",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "662-286-6369"
    },
    "taxonomies": [
        {
            "code": "207XX0005X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Orthopaedic Surgery, Sports Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09013928",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Corinth, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.