Basic Information
| Provider Information | |||||||||
| NPI: | 1013280486 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNOLIA COMMONS PEDIATRICS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARLILE PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 CAMBRIDGE CT | ||||||||
| Address2: | |||||||||
| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360931259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345676915 | ||||||||
| FaxNumber: | 3345147269 | ||||||||
| Practice Location | |||||||||
| Address1: | 78 CAMBRIDGE CT | ||||||||
| Address2: | |||||||||
| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360931259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345674311 | ||||||||
| FaxNumber: | 3345674312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2012 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | BRUCE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3345674311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 19637 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.