Provider Demographics
NPI:1275612665
Name:MAGNOLIA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MAGNOLIA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-534-6400
Mailing Address - Street 1:12921 FERN ST STE E
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4300
Mailing Address - Country:US
Mailing Address - Phone:714-899-8198
Mailing Address - Fax:714-899-8598
Practice Address - Street 1:12921 FERN ST STE E
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4300
Practice Address - Country:US
Practice Address - Phone:714-899-8198
Practice Address - Fax:714-899-8598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16567Medicare ID - Type Unspecified