Basic Information
| Provider Information | |||||||||
| NPI: | 1295914661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIERRA NEUROSURGERY GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5590 KIETZKE LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895113019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753232080 | ||||||||
| FaxNumber: | 7753238216 | ||||||||
| Practice Location | |||||||||
| Address1: | 5590 KIETZKE LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895113019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753232080 | ||||||||
| FaxNumber: | 7753238216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | GALLEGOS | ||||||||
| AuthorizedOfficialFirstName: | FLORA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7757893930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100508864 | 05 | NV | MEDICAID |