Provider Demographics
NPI:1386629558
Name:MAGNOLIA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:MAGNOLIA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:CORTINA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:864-621-5646
Mailing Address - Street 1:PO BOX 25306
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29616-0306
Mailing Address - Country:US
Mailing Address - Phone:864-752-3357
Mailing Address - Fax:678-840-2112
Practice Address - Street 1:800 PELHAM RD
Practice Address - Street 2:THIRD FLOOR - PHYSICAL THERAPY DEPARTMENT
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3300
Practice Address - Country:US
Practice Address - Phone:864-752-3357
Practice Address - Fax:678-840-2112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-11
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC225100000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3940Medicaid
SC8395Medicare ID - Type Unspecified