Provider Demographics
NPI:1063024149
Name:MAGNOLIA GYNECOLOGY, LLC
Entity Type:Organization
Organization Name:MAGNOLIA GYNECOLOGY, LLC
Other - Org Name:MAGNOLIA GYNECOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-773-6627
Mailing Address - Street 1:1000 W KENNEDY BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-1940
Mailing Address - Country:US
Mailing Address - Phone:813-773-6627
Mailing Address - Fax:813-443-6001
Practice Address - Street 1:3216 W AZEELE ST STE 2
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3018
Practice Address - Country:US
Practice Address - Phone:813-773-6627
Practice Address - Fax:813-443-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-19
Last Update Date:2023-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty