Provider Demographics
NPI:1811124456
Name:MAGNOLIA MIDLANDS PAIN MANAGEMENT
Entity type:Organization
Organization Name:MAGNOLIA MIDLANDS PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-530-7516
Mailing Address - Street 1:186 S. MACON STREET
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-1117
Mailing Address - Country:US
Mailing Address - Phone:912-530-7516
Mailing Address - Fax:912-530-7517
Practice Address - Street 1:186 S. MACON ST.
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-1117
Practice Address - Country:US
Practice Address - Phone:912-530-7516
Practice Address - Fax:912-530-7517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
GA062371207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA166390878AMedicaid
GA202G703902Medicare PIN
GA6373750001Medicare NSC
GA41146BMedicare UPIN