MEDICARE: MAGNOLIA MEDICAL COMPANY

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	207QA0401X	Addiction Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1952094476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA MEDICAL COMPANY

Provider Business Mailing Address
First Line	:	2925 E COLFAX AVE
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80206-1604
Country	:	US
Telephone Number	:	303-209-5115
Fax Number	:	833-603-0135

Provider Business Practice Location Address
First Line	:	9572 DUBLIN RD
Second Line	:
City	:	SHAWNEE HILLS
State	:	OH
Zip	:	43065-8973
Country	:	US
Telephone Number	:	303-209-5115
Fax Number	:	833-603-0135

Authorized Official
Title or Position	:	REVENUE CYCLE MANAGER
Name	:	SUSIE LERNER
Credential	:
Telephone Number	:	720-909-3890

Provider Enumeration Date	:	05/31/2023
Last Update Date	:	05/31/2023

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Directions to “MAGNOLIA MEDICAL COMPANY ” Practice Location

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