Provider Demographics
NPI:1306937974
Name:MAGNOLIA HOSPITALITY INC.
Entity type:Organization
Organization Name:MAGNOLIA HOSPITALITY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-874-3235
Mailing Address - Street 1:2475 BROADWAY BLUFFS DRIVE
Mailing Address - Street 2:STE. 301
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8128
Mailing Address - Country:US
Mailing Address - Phone:573-874-3235
Mailing Address - Fax:573-817-5917
Practice Address - Street 1:2475 BROADWAY BLUFFS DRIVE
Practice Address - Street 2:STE. 301
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8128
Practice Address - Country:US
Practice Address - Phone:573-874-3235
Practice Address - Fax:573-817-5917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509179305Medicaid
MO509179305Medicaid