Basic Information
| Provider Information | |||||||||
| NPI: | 1750911848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAGNOLIA ANESTHESIA MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7920 BELT LINE RD STE 940 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752548151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722344740 | ||||||||
| FaxNumber: | 9722317095 | ||||||||
| Practice Location | |||||||||
| Address1: | 3075 W SOUTHLAKE BLVD | ||||||||
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| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760926730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722344740 | ||||||||
| FaxNumber: | 9722317095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2020 | ||||||||
| LastUpdateDate: | 01/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | SILLER | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9722344740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.