Organization
PSP MEDICAL CLINIC LLC
Active
Other names
Magnolia Medical Clinics, MADISON CANTON MEDICAL CLINIC
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. NEELAM GOEL (MANAGER)
(601) 859-9888
Entity
Organization
Contact information
Practice address
1171 HART ST, CANTON, MS 39046-4805
(601) 859-9888
(601) 859-9966
Mailing address
P.O. BOX 607, CANTON, MS 39157
(601) 859-9888
(601) 859-9966
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
15405
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
25D1052898
CLIA
MS
Enumeration date
06/19/2006
Last updated
04/06/2021
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