=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013518265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA PRIMARY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2020
-----------------------------------------------------
Last Update Date | 01/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4245 BALMORAL DR SW STE 102
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35801-6456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-203-6676
-----------------------------------------------------
Fax | 833-979-0980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4245 BALMORAL DR SW STE 102
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35801-6456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-203-6676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. ROHINI RAMAMOORTHY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 256-203-6676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------