MEDICARE: MAGNOLIA PEDIATRICS 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	208000000X	Pediatrics Physician	ME72652	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	061823792	OTHER	FL	TRICARE

General Provider Information

NPI Number	:	1356513964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA PEDIATRICS LLC

Provider Business Mailing Address
First Line	:	1140 SW BASCOM NORRIS DR STE 104
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-1329
Country	:	US
Telephone Number	:	386-719-6500
Fax Number	:	386-719-6503

Provider Business Practice Location Address
First Line	:	1140 SW BASCOM NORRIS DR STE 104
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-1329
Country	:	US
Telephone Number	:	386-719-6500
Fax Number	:	386-719-6503

Authorized Official
Title or Position	:	PROVIDER
Name	:	DR. BILAL KHODR
Credential	:	MD
Telephone Number	:	386-719-6500

Provider Enumeration Date	:	03/24/2008
Last Update Date	:	10/05/2012

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