1013066125 NPI number — MARK F SEVERINO MD

Table of content: MARK F SEVERINO MD (NPI 1013066125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013066125 NPI number — MARK F SEVERINO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEVERINO
Provider First Name:
MARK
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1013066125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5320 S. RAINBOW BLVD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89118-1986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-794-0073
Provider Business Mailing Address Fax Number:
702-794-0042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5320 S. RAINBOW BLVD
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89118-1986
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-794-0073
Provider Business Practice Location Address Fax Number:
702-794-0042
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  44505 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VE0102X , with the licence number: 7453 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34243800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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