Provider Demographics
NPI:1427232776
Name:MAGNOLIA SPRINGS PEDIATRICS PC
Entity Type:Organization
Organization Name:MAGNOLIA SPRINGS PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-965-5088
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:36555-0307
Mailing Address - Country:US
Mailing Address - Phone:251-965-3320
Mailing Address - Fax:251-965-3315
Practice Address - Street 1:14975 HWY 98
Practice Address - Street 2:
Practice Address - City:MAGNOLIA SPRINGS
Practice Address - State:AL
Practice Address - Zip Code:36555-0307
Practice Address - Country:US
Practice Address - Phone:251-965-3320
Practice Address - Fax:251-965-3315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD7965208000000X
ALMD27137208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009942429OtherROBERT L RUX
AL000008277Medicaid