1124334776 NPI number — TAHOE CARSON VALLEY MEDICAL GROUP, INC.

Table of content: (NPI 1124334776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124334776 NPI number — TAHOE CARSON VALLEY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAHOE CARSON VALLEY MEDICAL GROUP, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1124334776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 EMERALD BAY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH LAKE TAHOE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96150-6207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-543-5659
Provider Business Mailing Address Fax Number:
530-541-8723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 HWY 50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATELINE
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89449-9800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-589-8900
Provider Business Practice Location Address Fax Number:
775-588-7110
Provider Enumeration Date:
08/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BERGNER
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
WALTER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
775-589-8900

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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