MEDICARE: MAGNOLIA PSYCHIATRY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0802X	Addiction Psychiatry Physician	MD00036813	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MD00036813	OTHER	WA	WASHINGTON STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1003346594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA PSYCHIATRY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 7239
Second Line	:
City	:	BELLEVUE
State	:	WA
Zip	:	98008-1239
Country	:	US
Telephone Number	:	425-467-1000
Fax Number	:	425-467-0100

Provider Business Practice Location Address
First Line	:	12729 NORTHUP WAY STE 6
Second Line	:
City	:	BELLEVUE
State	:	WA
Zip	:	98005-1935
Country	:	US
Telephone Number	:	425-467-1000
Fax Number	:	425-467-0100

Authorized Official
Title or Position	:	PSYCHIATRIST
Name	:	MARC DAVID PELLICCIARO
Credential	:	MD
Telephone Number	:	425-467-1000

Provider Enumeration Date	:	06/15/2017
Last Update Date	:	04/17/2019

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