Provider Demographics
NPI:1922639897
Name:MAGNOLIA ENDOCRINOLOGY, LLC
Entity Type:Organization
Organization Name:MAGNOLIA ENDOCRINOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEMPLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEWSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:854-201-3636
Mailing Address - Street 1:204 PARSONS RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-3348
Mailing Address - Country:US
Mailing Address - Phone:854-201-3636
Mailing Address - Fax:854-201-1983
Practice Address - Street 1:204 PARSONS RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-3348
Practice Address - Country:US
Practice Address - Phone:854-201-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-30
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCK109Medicaid