=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245278365
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA HEALTHCARE CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 07/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18602 FM 1488 RD STE 700
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77354-8508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-356-2525
-----------------------------------------------------
Fax | 281-356-2920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18602 FM 1488 RD STE 700
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77354-8508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-356-2525
-----------------------------------------------------
Fax | 281-356-2920
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | EDWARD L TERRASSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 281-356-2525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | L1477
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------