MEDICARE: MAGNOLIA MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	207RA0401X	Addiction Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1003672619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 29605
Second Line	:	DEPT # 800927
City	:	PHOENIX
State	:	AZ
Zip	:	85038-9605
Country	:	US
Telephone Number	:	303-209-5115
Fax Number	:	720-638-5562

Provider Business Practice Location Address
First Line	:	1490 N LAFAYETTE ST STE 104
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80218-2391
Country	:	US
Telephone Number	:	303-209-5115
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	PRADEEP RAI
Credential	:
Telephone Number	:	303-209-5115

Provider Enumeration Date	:	02/22/2024
Last Update Date	:	02/17/2026

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Directions to “MAGNOLIA MEDICAL GROUP ” Practice Location

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