Provider Demographics
NPI:1639281652
Name:MAGNOLIA MEDICAL CLINIC P.A.
Entity Type:Organization
Organization Name:MAGNOLIA MEDICAL CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SITES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-243-7681
Mailing Address - Street 1:319 GREEN ACRES RD STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1170
Mailing Address - Country:US
Mailing Address - Phone:850-243-7681
Mailing Address - Fax:850-243-0471
Practice Address - Street 1:319 GREEN ACRES RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-243-7681
Practice Address - Fax:850-243-0471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254841100Medicaid
FLCH5541OtherRAIL ROAD
=========OtherTAX ID
FLCH5541OtherRAIL ROAD