Provider Demographics
NPI:1184711517
Name:MAGNOLIA MEDICAL CLINIC, P.C.
Entity type:Organization
Organization Name:MAGNOLIA MEDICAL CLINIC, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-931-1333
Mailing Address - Street 1:PO BOX 1553
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096
Mailing Address - Country:US
Mailing Address - Phone:770-931-1333
Mailing Address - Fax:770-931-3111
Practice Address - Street 1:1235 INDIAN TRAIL ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093
Practice Address - Country:US
Practice Address - Phone:770-931-1333
Practice Address - Fax:770-931-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP1910Medicare PIN