Basic Information
Provider Information | |||||||||
NPI: | 1659856631 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTERN SIERRA MEDICAL GROUP LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RENOWN MEDICAL GROUP - MULTISPECIALTY CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1155 MILL ST # M14 | ||||||||
Address2: |   | ||||||||
City: | RENO | ||||||||
State: | NV | ||||||||
PostalCode: | 895021576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7759825262 | ||||||||
FaxNumber: | 7759825496 | ||||||||
Practice Location | |||||||||
Address1: | 1500 E 2ND ST STE 300 | ||||||||
Address2: |   | ||||||||
City: | RENO | ||||||||
State: | NV | ||||||||
PostalCode: | 895021198 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7759826270 | ||||||||
FaxNumber: | 7759826271 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2018 | ||||||||
LastUpdateDate: | 03/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BECK | ||||||||
AuthorizedOfficialFirstName: | ANN | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7759826488 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HOMETOWN HEALTH MANAGEMENT COMPANY | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 208600000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.