Magnolia Pediatrics LLC

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

ME72652 Issued in FL

Legal business name

MAGNOLIA PEDIATRICS LLC

Practice address

1140 SW Bascom Norris Dr Ste 104
Lake City, FL 32025-1329

Phone

(386) 719-6500

Fax

(386) 719-6503

NPI assigned

Mar 24, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Bilal Khodr, MDNPI 1881653723

Title

Provider

Phone

(386) 719-6500

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356513964. Details of each certification follow.

• CCN 683808 Rural health clinic · Active · Name & address match · Details

Rural health clinic certification: CCN 683808

Legal name

MAGNOLIA PEDIATRICS

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Jun 17, 2013

Last certification

Feb 7, 2020

Ownership / control type

For profit – corporation

Facility address

1140 SW Bascom Norris Dr Ste 104
Lake City, FL 32025

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Bilal Khodr, M.D.

  • Pediatrics Physician
  • Gainesville, FL
  • NPI 1881653723
  NPD (past) Authorized official
• Stacey Cervantes, ARNP

  • Nurse Practitioner
  • Lake City, FL
  • NPI 1629077144
  NPD (past)
• Jamilyn Vaughn Jordan, MSN, ARNP, PNP-PC

  • Pediatric Nurse Practitioner
  • Lake City, FL
  • NPI 1639736580
  NPD (past)
• Lorielle Manning Lang, APRN

  • Pediatric Nurse Practitioner
  • Lake City, FL
  • NPI 1275114001
  NPD (past)
• Samantha Lawrence, ARNP, PNP-PC

  • Pediatric Nurse Practitioner
  • Lake City, FL
  • NPI 1053829549
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1206316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1349395200000",
    "number": "1356513964",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1140 SW BASCOM NORRIS DR STE 104",
            "city": "LAKE CITY",
            "state": "FL",
            "postal_code": "320251329",
            "telephone_number": "386-719-6500",
            "fax_number": "386-719-6503"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1140 SW BASCOM NORRIS DR STE 104",
            "city": "LAKE CITY",
            "state": "FL",
            "postal_code": "320251329",
            "telephone_number": "386-719-6500",
            "fax_number": "386-719-6503"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAGNOLIA PEDIATRICS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-03-24",
        "last_updated": "2012-10-05",
        "status": "A",
        "authorized_official_last_name": "KHODR",
        "authorized_official_first_name": "BILAL",
        "authorized_official_title_or_position": "PROVIDER",
        "authorized_official_telephone_number": "386-719-6500",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": "FL",
            "license": "ME72652",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TRICARE",
            "identifier": "061823792",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Dylan Madison, PHARM D
• Zara Elizabeth Magana
• Magnolia Adult
• Magnolia Adult
• Magnolia Family Care Corp (Urolife Wellness)
• Cynthia Bautista Magrini, MD
• Thomas Bennett Mahan II, RRT
• Heather Marie Mahoney, LCSW
• Lauren Maloney, MSCAP
• Patrick Maltba

• Pediatrics Physician in Lake City, FL
• Providers in Lake City, FL by specialty
• Pediatrics Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 5, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.