1386629558 NPI number — MAGNOLIA MEDICAL GROUP INC

Table of content: (NPI 1386629558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386629558 NPI number — MAGNOLIA MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386629558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29616-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-752-3357
Provider Business Mailing Address Fax Number:
678-840-2112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 PELHAM RD
Provider Second Line Business Practice Location Address:
THIRD FLOOR - PHYSICAL THERAPY DEPARTMENT
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615-3300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-752-3357
Provider Business Practice Location Address Fax Number:
678-840-2112
Provider Enumeration Date:
12/11/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CORTINA
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
864-621-5646

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP3940 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".