PSP Medical Clinic LLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

License

15405 Issued in MS

Legal business name

PSP MEDICAL CLINIC LLC

Practice address

1171 Hart St
Canton, MS 39046-4805

Phone

(601) 859-9888

Fax

(601) 859-9004

NPI assigned

May 3, 2011

Organization subpart

No

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

Authorized official

Name

Dr. Parvesh K. Goel, MDNPI 1548219082

Title

MD

Phone

(662) 746-3555

Specialties & licenses 1

Addresses

Other identifiers 5

Other names 2

• MAGNOLIA MEDICAL CLINICS Doing business as
• MAGNOLIA MEDICAL CLINICS YAZOO Doing business as

Medicare fee-for-service enrollment

Enrolled in MS2 enrollments

Enrollment records 2

Rural health clinic certification: CCN 258999

Legal name

PSP MEDICAL CLINIC LLC

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Nov 12, 2007

Last certification

Oct 7, 2021

Ownership / control type

1A

Organization structure

LLCProprietary

Incorporated

Jul 29, 2002 in MS

Enrollment address

1171 Hart St
Canton, MS 39046-4805

Rural health clinic certification: CCN 253855

Legal name

PSP MEDICAL CLINIC LLC

Doing business as

MAGNOLIA MEDICAL CLINICS

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Sep 21, 2012

Last certification

Sep 5, 2019

Ownership / control type

1A

Organization structure

LLCProprietary

Enrollment address

1435 Grand Ave
Yazoo Family Clinic
Yazoo City, MS 39194-2651

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• PSP Medical Clinic LLC

  • Rural Health Clinic/Center
  • Canton, MS
  • NPI 1932144243

  6406859446

  Same PAC ID

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

• PSP Medical Clinic

  • Primary Care Clinic/Center
  • Flowood, MS
  • NPI 1245502723

  O20061113000513

  Same enrollment
• PSP Medical Clinic

  • Primary Care Clinic/Center
  • Gluckstadt, MS
  • NPI 1245581370

  O20061113000513

  Same enrollment
• PSP Medical Clinic LLC

  • Rural Health Clinic/Center
  • Canton, MS
  • NPI 1932144243

  O20061113000513

  Same enrollment

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

Flowood Family Clinic4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

• PSP Medical Clinic

  • Primary Care Clinic/Center
  • Flowood, MS
  • NPI 1245502723
  NPD tax ID
• PSP Medical Clinic

  • Primary Care Clinic/Center
  • Gluckstadt, MS
  • NPI 1245581370
  NPD tax ID
• PSP Medical Clinic LLC

  • Rural Health Clinic/Center
  • Canton, MS
  • NPI 1932144243
  NPD tax ID

Locations

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Parvesh K Goel, M.D.

  • Internal Medicine Physician
  • Canton, MS
  • NPI 1548219082

  5% Or Greater Direct Ownership Interest, Corporate Officer, W-2 Managing Employee

  CMS ownership

Practitioners 1

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

• Parvesh K Goel, M.D.

  • Internal Medicine Physician
  • Canton, MS
  • NPI 1548219082
  NPD (past) Authorized official

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

{
    "created_epoch": "1304380800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707177600000",
    "number": "1225320708",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 607",
            "city": "CANTON",
            "state": "MS",
            "postal_code": "390460607",
            "telephone_number": "662-746-3555",
            "fax_number": "601-859-9966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1171 HART ST",
            "city": "CANTON",
            "state": "MS",
            "postal_code": "390464805",
            "telephone_number": "601-859-9888",
            "fax_number": "601-859-9004"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2629 Courthouse Cir",
            "address_purpose": "LOCATION",
            "city": "Flowood",
            "state": "MS",
            "postal_code": "392329521",
            "country_code": "US",
            "telephone_number": "601-420-4300",
            "fax_number": "601-420-4310",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1435 Grand Ave",
            "address_purpose": "LOCATION",
            "city": "Yazoo City",
            "state": "MS",
            "postal_code": "391942651",
            "country_code": "US",
            "telephone_number": "662-746-3555",
            "fax_number": "662-746-5211",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1082A Gluckstadt Rd",
            "address_purpose": "LOCATION",
            "city": "Madison",
            "state": "MS",
            "postal_code": "391107243",
            "country_code": "US",
            "telephone_number": "601-707-5621",
            "fax_number": "601-707-5627",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PSP MEDICAL CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-03",
        "last_updated": "2024-02-06",
        "certification_date": "2024-02-06",
        "status": "A",
        "authorized_official_last_name": "GOEL",
        "authorized_official_first_name": "PARVESH",
        "authorized_official_middle_name": "K.",
        "authorized_official_title_or_position": "MD",
        "authorized_official_telephone_number": "662-746-3555",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MS",
            "license": "15405",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "06572715",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "07228530",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00118231",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02679823",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09238061",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MAGNOLIA MEDICAL CLINICS",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "MAGNOLIA MEDICAL CLINICS",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "MAGNOLIA MEDICAL CLINICS YAZOO",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Providers in Canton, MS by specialty
• Rural Health Clinic/Center in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.