Basic Information
| Provider Information | |||||||||
| NPI: | 1417080839 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDSCHOOL ASSOCIATES SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29506 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891269506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029684371 | ||||||||
| FaxNumber: | 7026715170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1707 W CHARLESTON BLVD | ||||||||
| Address2: | 110B | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029684363 | ||||||||
| FaxNumber: | 7026710193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PALMER | ||||||||
| AuthorizedOfficialFirstName: | ELISSA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7029926888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Biochemical Genetics | 207SG0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Molecular Genetics | 207SG0205X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Ph.D. Medical Genetics | 207SM0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Molecular Genetic Pathology | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 207SC0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Cytogenetic |
ID Information
| ID | Type | State | Issuer | Description | 100500484 | 05 | NV | MEDICAID |