Add an Additional Location

Magnolia Health asks that additional addresses only be requested for practitioners that display on the directory. Additional address are utilized for directory purposes only and are not needed for claims payment.

Magnolia Health will not process additional address requests for these practitioner types: Emergency Medicine, Radiology, Anesthesiology (excluding Pain Management), Pathology, CRNA, Midwives, Occupational Therapy, Mid-levels not acting as a PCP holding a panel, and Practitioners who practice exclusively in a facility setting.

Group/Facility Name *

Group Mississippi Medicaid Number *

Tax ID Number *

Group NPI Number *

Practitioner First Name

Practitioner Last Name

Practitioner NPI

Multiple Practitioners

If multiple practitioners are adding this address as an additional location, please attach a spreadsheet with their names and NPI numbers.

Additional Location Address

Street Address *

Address Line 2

City *

State *

ZIP / Postal Code *

Appointment Phone Number *

Location Phone Number *

Office Hours (Monday) *

Office Hours (Tuesday) *

Office Hours (Wednesday) *

Office Hours (Thursday) *

Office Hours (Friday) *

Office Hours (Saturday) *

Office Hours (Sunday) *

Comments

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone *

Last Updated: 09/18/2024