Provider Demographics
NPI:1386282838
Name:MAGNOLIA FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:MAGNOLIA FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:803-905-2273
Mailing Address - Street 1:1229 ALICE DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1970
Mailing Address - Country:US
Mailing Address - Phone:803-905-2273
Mailing Address - Fax:
Practice Address - Street 1:1229 ALICE DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1970
Practice Address - Country:US
Practice Address - Phone:803-905-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty