Provider Demographics
NPI:1194287680
Name:MAGNOLIA PEDIATRICS OF MARIN, INC.
Entity type:Organization
Organization Name:MAGNOLIA PEDIATRICS OF MARIN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-380-8700
Mailing Address - Street 1:655 REDWOOD HWY FRONTAGE RD STE 216
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 REDWOOD HWY FRONTAGE RD STE 216
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3055
Practice Address - Country:US
Practice Address - Phone:415-380-8711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty