Provider Demographics
NPI:1932889102
Name:MAGNOLIA DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:MAGNOLIA DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-888-2012
Mailing Address - Street 1:1 LOUDON HTS S
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12211-2013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:582 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4059
Practice Address - Country:US
Practice Address - Phone:518-888-2012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-21
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty