Healthcare Provider Details

I. General information

NPI: 1851976054
Provider Name (Legal Business Name): MAGNOLIA MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 04/09/2022
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 AL HIGHWAY 68 W
SANDROCK AL
35983-4200
US

IV. Provider business mailing address

2820 AL HIGHWAY 68 W
SANDROCK AL
35983-4200
US

V. Phone/Fax

Practice location:
  • Phone: 205-386-4341
  • Fax: 256-523-1503
Mailing address:
  • Phone: 256-523-3627
  • Fax: 256-523-1503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ENRICO D GASPAR
Title or Position: OWNER
Credential: MD
Phone: 256-840-8181