Basic Information
| Provider Information | |||||||||
| NPI: | 1861448219 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNOLIA REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MAGNOLIA BREASTCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 629 | ||||||||
| Address2: | |||||||||
| City: | MAGNOLIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717540629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702353000 | ||||||||
| FaxNumber: | 8702353667 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MAGNOLIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717532415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702353000 | ||||||||
| FaxNumber: | 8702353667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | REX | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8702353212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography |
ID Information
| ID | Type | State | Issuer | Description | 770005905 | 01 | AR | BREASTCARE | OTHER |