Basic Information
| Provider Information | |||||||||
| NPI: | 1164555736 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO. | ||||||||
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| OtherOrganizationName: | MEDSCHOOL ASSOCIATES SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98528 | ||||||||
| Address2: | DEPT 401 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891938528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026712395 | ||||||||
| FaxNumber: | 7023825388 | ||||||||
| Practice Location | |||||||||
| Address1: | 2410 FIRE MESA ST | ||||||||
| Address2: | STE 180 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891289016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029926888 | ||||||||
| FaxNumber: | 7029926880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | ZAMBONI | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE DEAN | ||||||||
| AuthorizedOfficialTelephone: | 7026712278 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.