Provider Demographics
NPI:1316916810
Name:MAGNOLIA PATHOLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:MAGNOLIA PATHOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ODELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-352-5301
Mailing Address - Street 1:PO BOX 2245
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92516-2245
Mailing Address - Country:US
Mailing Address - Phone:661-705-3441
Mailing Address - Fax:951-848-0999
Practice Address - Street 1:3865 JACKSON ST
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3919
Practice Address - Country:US
Practice Address - Phone:951-352-5301
Practice Address - Fax:951-352-5340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAW462AOtherMEDICARE PTAN
DO4317OtherRAILROAD MEDICARE GROUP PTAN
CA00G767400Medicaid