Basic Information
| Provider Information | |||||||||
| NPI: | 1437196979 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY SPECIALISTS LTD MARASSO-MILLER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4101 WAGON TRAIL AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891184426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029424123 | ||||||||
| FaxNumber: | 7029424124 | ||||||||
| Practice Location | |||||||||
| Address1: | 3186 S MARYLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891092317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8649871833 | ||||||||
| FaxNumber: | 7029424124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAUSSADE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7029424121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200290200 | 05 | NV | MEDICAID | NV3237 | 01 | NV | BLUE | OTHER |