MEDICARE: MAGNOLIA PLASTIC SURGERY & MEDSPA

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	2086S0122X	Plastic and Reconstructive Surgery Physician
2	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1376220814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA PLASTIC SURGERY & MEDSPA

Provider Business Mailing Address
First Line	:	4500 MAGAZINE ST STE 1
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70115-1543
Country	:	US
Telephone Number	:	504-571-5908
Fax Number	:	504-571-5953

Provider Business Practice Location Address
First Line	:	4500 MAGAZINE ST STE 1
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70115-1575
Country	:	US
Telephone Number	:	504-608-7863
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HEATH CHARVET
Credential	:	MD
Telephone Number	:	504-621-8934

Provider Enumeration Date	:	06/28/2023
Last Update Date	:	05/22/2024

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