Provider Demographics
NPI:1598212185
Name:MAGNOLIA FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:MAGNOLIA FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:BRYCE
Authorized Official - Last Name:SWALM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-267-6249
Mailing Address - Street 1:3 CERITOS TRAIL
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403-0300
Mailing Address - Country:US
Mailing Address - Phone:304-267-6249
Mailing Address - Fax:304-267-6248
Practice Address - Street 1:3 CERITOS TRAIL
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-0300
Practice Address - Country:US
Practice Address - Phone:304-267-6249
Practice Address - Fax:304-267-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1962745950Medicaid
WVWV6720G238Medicare PIN