Provider Demographics
NPI:1972582385
Name:MAGNOLIA INTERNAL MEDICINE ASSOCIATES PA
Entity type:Organization
Organization Name:MAGNOLIA INTERNAL MEDICINE ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:IONE
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-565-0303
Mailing Address - Street 1:3309 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-565-0303
Mailing Address - Fax:903-565-5446
Practice Address - Street 1:3309 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-565-0303
Practice Address - Fax:903-565-5446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0057LZOtherBCBS
0057LZOtherBCBS