Provider Demographics
NPI:1982959615
Name:MAGNOLIA SURGERY, PC
Entity Type:Organization
Organization Name:MAGNOLIA SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-287-6574
Mailing Address - Street 1:1118 HIGHWAY 96 WEST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047
Mailing Address - Country:US
Mailing Address - Phone:478-287-6574
Mailing Address - Fax:478-287-6579
Practice Address - Street 1:1118 HIGHWAY 96 WEST
Practice Address - Street 2:SUITE 1
Practice Address - City:KATHLEEN
Practice Address - State:GA
Practice Address - Zip Code:31047
Practice Address - Country:US
Practice Address - Phone:478-287-6574
Practice Address - Fax:478-287-6579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23837208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1669674909OtherINDIVIDUAL NPI#
GA003130442AMedicaid