Healthcare Provider Details

I. General information

NPI: 1316916810
Provider Name (Legal Business Name): MAGNOLIA PATHOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3865 JACKSON ST DEPT OF PATHOLOGY
RIVERSIDE CA
92503-3919
US

IV. Provider business mailing address

PO BOX 2245
RIVERSIDE CA
92516-2245
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-5301
  • Fax: 951-352-5340
Mailing address:
  • Phone: 661-705-3441
  • Fax: 951-848-0999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: CATHERINE ODELL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-352-5301