Healthcare Provider Details

I. General information

NPI: 1194287680
Provider Name (Legal Business Name): MAGNOLIA PEDIATRICS OF MARIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 REDWOOD HWY FRONTAGE RD STE 216
MILL VALLEY CA
94941-3055
US

IV. Provider business mailing address

655 REDWOOD HWY FRONTAGE RD STE 216
MILL VALLEY CA
94941-3055
US

V. Phone/Fax

Practice location:
  • Phone: 415-380-8711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SUZANNE CHRISTIE
Title or Position: PRESIDENT
Credential: MD
Phone: 415-380-8700