Healthcare Provider Details

I. General information

NPI: 1760442164
Provider Name (Legal Business Name): MAGNOLIA PEDIATRICS SOUTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 11TH AVE S
BIRMINGHAM AL
35205-4703
US

IV. Provider business mailing address

1621 11TH AVE S
BIRMINGHAM AL
35205-4703
US

V. Phone/Fax

Practice location:
  • Phone: 205-930-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL AMAMOO
Title or Position: SECT-TREASURER
Credential:
Phone: 205-930-9500