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General NPI Number Information
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NPI Number | 1770459299
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Entity Type | Organization
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Legal Business Name | MAGNOLIA MEDICINE DPC
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Dates
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Enumeration Date | 10/13/2025
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Last Update Date | 10/13/2025
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Provider Practice Location Address
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Address Line | 600 WADE AVE STE A
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City | RALEIGH
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State | NC
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Zip | 27605-3121
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Country | US
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Telephone | 919-228-8155
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Fax | 984-220-9276
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Provider Business Mailing Address
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Address Line | 600 WADE AVE STE A
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City | RALEIGH
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State | NC
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Zip | 27605-3121
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Country | US
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Telephone | 919-228-8155
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Fax | 984-220-9276
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Authorized Official
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Title or Position | PHYSICIAN OWNER
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Name | JOHANNA HADLEY SAMPSON
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Credential | MD
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Telephone | 317-697-8490
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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