Healthcare Provider Details

I. General information

NPI: 1043769862
Provider Name (Legal Business Name): MAGNOLIA MEDICAL COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 E COLFAX AVE
DENVER CO
80206-1604
US

IV. Provider business mailing address

1850 RACE ST
DENVER CO
80206-1116
US

V. Phone/Fax

Practice location:
  • Phone: 303-209-5115
  • Fax: 720-638-5562
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number06D2121590
License Number StateCO
# 6
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: PRADEEP RAJ RAI
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 303-209-5115