Magnolia Medical LLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

MAGNOLIA MEDICAL LLC

Doing business as

United Doctors Family Medical Center Sand Rock

Practice address

2820 Al Highway 68 W
Sandrock, AL 35983-4200

Phone

(205) 386-4341

Fax

(256) 523-1503

NPI assigned

Mar 10, 2021

Last updated

Apr 9, 2022By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Enrico D Gaspar, MDNPI 1497740492

Title

Owner

Phone

(256) 840-8181

Specialties & licenses 3

Addresses

Other names 1

• United Doctors Family Medical Center Sand Rock Doing business as

Medicare fee-for-service enrollment

Enrolled in AL2 enrollments

Enrollment records 2

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1851976054. Details of each certification follow.

• CCN 018956 Rural health clinic · Active · Details

Rural health clinic certification: CCN 018956

Legal name

MAGNOLIA MEDICAL LLC

Doing business as

UNITED DOCTORS FAMILY MEDICAL CENTER- SAND ROCK

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

Jul 12, 2021

Last certification

Jul 8, 2021

Ownership / control type

1C

Organization structure

LLCProprietary

Enrollment address

2820 Al Highway 68 W
Sandrock, AL 35983-4200

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

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Enrico D Gaspar, M.D.

  • Internal Medicine Physician
  • Boaz, AL
  • NPI 1497740492

  5% Or Greater Direct Ownership Interest, Corporate Officer, Operational/Managerial Control

  CMS ownership
• Ashley Coby Lackey, CRNP

  • Nurse Practitioner
  • Smiths Station, AL
  • NPI 1679847487

  5% Or Greater Direct Ownership Interest, Corporate Officer, Operational/Managerial Control

  CMS ownership

Practitioners 7

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.

• Enrico D Gaspar, M.D.

  • Internal Medicine Physician
  • Boaz, AL
  • NPI 1497740492
  Medicare reassignment Care Compare group NPD Authorized official
• Casey Marie Rains Gossett, CRNP

  • Family Nurse Practitioner
  • Sandrock, AL
  • NPI 1598519373
  Medicare reassignment Care Compare group NPD
• Ashley Coby Lackey, CRNP

  • Nurse Practitioner
  • Smiths Station, AL
  • NPI 1679847487
  Medicare reassignment Care Compare group NPD
• Ethan Caleb Bonds, CRNP

  • Family Nurse Practitioner
  • Boaz, AL
  • NPI 1154082758
  Medicare reassignment NPD
• Ashley Brooke Bozarth, CRNP

  • Internal Medicine Physician
  • Altoona, AL
  • NPI 1184439184
  Medicare reassignment NPD
• Joni Kelley, CRNP

  • Family Nurse Practitioner
  • Boaz, AL
  • NPI 1851023543
  Medicare reassignment NPD
• Lauren Loveless, CRNP

  • Family Nurse Practitioner
  • Snead, AL
  • NPI 1073198271
  Medicare reassignment NPD

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

{
    "created_epoch": "1615334400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1649462400000",
    "number": "1851976054",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2820 AL HIGHWAY 68 W",
            "city": "SANDROCK",
            "state": "AL",
            "postal_code": "359834200",
            "telephone_number": "256-523-3627",
            "fax_number": "256-523-1503"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2820 AL HIGHWAY 68 W",
            "city": "SANDROCK",
            "state": "AL",
            "postal_code": "359834200",
            "telephone_number": "205-386-4341",
            "fax_number": "256-523-1503"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAGNOLIA MEDICAL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-03-10",
        "last_updated": "2022-04-09",
        "certification_date": "2022-04-09",
        "status": "A",
        "authorized_official_last_name": "GASPAR",
        "authorized_official_first_name": "ENRICO",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "256-840-8181",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "United Doctors Family Medical Center Sand Rock",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Casey Marie Rains Gossett, CRNP
• Tammie Mullins Graves, C.N.A.
• Leesburg Pharmacy, Inc. Dba Lookout Mountain Pharmacy (Lookout Mountain Pharmacy)
• Michael Mosley
• The Family First Health Clinic at the Rock

• Family Medicine Physician in Sandrock, AL
• Providers in Sandrock, AL by specialty
• Family Medicine Physician in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2022; 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.