MEDICARE: MAGNOLIA ENDOCRINOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922639897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA ENDOCRINOLOGY, LLC

Provider Business Mailing Address
First Line	:	204 PARSONS RD
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29483-3348
Country	:	US
Telephone Number	:	854-201-3636
Fax Number	:	854-201-1983

Provider Business Practice Location Address
First Line	:	204 PARSONS RD
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29483-3348
Country	:	US
Telephone Number	:	854-201-3636
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TEMPLE MEWSHAW
Credential	:
Telephone Number	:	854-201-3636

Provider Enumeration Date	:	01/30/2020
Last Update Date	:	01/21/2022

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