Healthcare Provider Details

I. General information

NPI: 1013280486
Provider Name (Legal Business Name): MAGNOLIA COMMONS PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 CAMBRIDGE CT
WETUMPKA AL
36093-1259
US

IV. Provider business mailing address

78 CAMBRIDGE CT
WETUMPKA AL
36093-1259
US

V. Phone/Fax

Practice location:
  • Phone: 334-567-4311
  • Fax: 334-567-4312
Mailing address:
  • Phone: 334-567-6915
  • Fax: 334-514-7269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number19637
License Number StateAL

VIII. Authorized Official

Name: MICHAEL D BRUCE
Title or Position: CEO
Credential:
Phone: 334-567-4311