Provider Demographics
NPI:1013280486
Name:MAGNOLIA COMMONS PEDIATRICS LLC
Entity Type:Organization
Organization Name:MAGNOLIA COMMONS PEDIATRICS LLC
Other - Org Name:CARLILE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-567-4311
Mailing Address - Street 1:78 CAMBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36093-1259
Mailing Address - Country:US
Mailing Address - Phone:334-567-6915
Mailing Address - Fax:334-514-7269
Practice Address - Street 1:78 CAMBRIDGE CT
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36093-1259
Practice Address - Country:US
Practice Address - Phone:334-567-4311
Practice Address - Fax:334-567-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL196372080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty