Basic Information
| Provider Information | |||||||||
| NPI: | 1316925381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN SIERRA MEDICAL GROUP LLC | ||||||||
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| OtherOrganizationName: | SILVER SPRINGS RURAL HEALTH CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1155 MILL ST # M14 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 3595 US HIGHWAY 50 | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRINGS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894299613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7755772117 | ||||||||
| FaxNumber: | 7755772769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | BECK | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7759826488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOMETOWN HEALTH MANAGEMENT COMPANY | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QR1300X | 7714RHC-0 | NV | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | CJ7646 | 01 | NV | RR MEDICARE PTAN | OTHER | 1316925381 | 05 | NV | MEDICAID |