1417080839 NPI number — UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO

Table of content: (NPI 1417080839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417080839 NPI number — UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDSCHOOL ASSOCIATES SOUTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417080839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 29506
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89126-9506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-968-4371
Provider Business Mailing Address Fax Number:
702-671-5170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1707 W CHARLESTON BLVD
Provider Second Line Business Practice Location Address:
110B
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89102-2351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-968-4363
Provider Business Practice Location Address Fax Number:
702-671-0193
Provider Enumeration Date:
03/14/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PALMER
Authorized Official First Name:
ELISSA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
702-992-6888

Provider Taxonomy Codes

  • Taxonomy code: 207SC0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207SG0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207SG0203X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207SG0205X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207SM0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100500484 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".