Provider Demographics
NPI:1851976054
Name:MAGNOLIA MEDICAL LLC
Entity Type:Organization
Organization Name:MAGNOLIA MEDICAL LLC
Other - Org Name:UNITED DOCTORS FAMILY MEDICAL CENTER SAND ROCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ENRICO
Authorized Official - Middle Name:D
Authorized Official - Last Name:GASPAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-840-8181
Mailing Address - Street 1:2820 AL HIGHWAY 68 W
Mailing Address - Street 2:
Mailing Address - City:SANDROCK
Mailing Address - State:AL
Mailing Address - Zip Code:35983-4200
Mailing Address - Country:US
Mailing Address - Phone:256-523-3627
Mailing Address - Fax:256-523-1503
Practice Address - Street 1:2820 AL HIGHWAY 68 W
Practice Address - Street 2:
Practice Address - City:SANDROCK
Practice Address - State:AL
Practice Address - Zip Code:35983-4200
Practice Address - Country:US
Practice Address - Phone:205-386-4341
Practice Address - Fax:256-523-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty