Healthcare Provider Details

I. General information

NPI: 1982959615
Provider Name (Legal Business Name): MAGNOLIA SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 HIGHWAY 96 WEST SUITE 1
KATHLEEN GA
31047
US

IV. Provider business mailing address

1118 HIGHWAY 96 WEST SUITE 1
KATHLEEN GA
31047
US

V. Phone/Fax

Practice location:
  • Phone: 478-287-6574
  • Fax: 478-287-6579
Mailing address:
  • Phone: 478-287-6574
  • Fax: 478-287-6579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number23837
License Number StateGA

VIII. Authorized Official

Name: DR. KERRY C. RODGERS
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 478-287-6574