Provider Demographics
NPI:1003672619
Name:MAGNOLIA MEDICAL GROUP
Entity Type:Organization
Organization Name:MAGNOLIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PRADEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:RAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-209-5115
Mailing Address - Street 1:2925 E COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-1604
Mailing Address - Country:US
Mailing Address - Phone:303-209-5115
Mailing Address - Fax:
Practice Address - Street 1:1490 N LAFAYETTE ST STE 104
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-2391
Practice Address - Country:US
Practice Address - Phone:303-209-5115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty