Provider Demographics
NPI:1639319213
Name:MAGNOLIA FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:MAGNOLIA FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:GUTSIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:910-796-3212
Mailing Address - Street 1:3720 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6147
Mailing Address - Country:US
Mailing Address - Phone:910-796-3212
Mailing Address - Fax:910-796-3216
Practice Address - Street 1:3720 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6147
Practice Address - Country:US
Practice Address - Phone:910-796-3212
Practice Address - Fax:910-796-3216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7937920Medicaid
NC7937920Medicaid