Basic Information
Provider Information | |||||||||
NPI: | 1689615262 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASEY | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1701 W CHARLESTON BLVD | ||||||||
Address2: | #215 | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891022325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026712395 | ||||||||
FaxNumber: | 7023825388 | ||||||||
Practice Location | |||||||||
Address1: | 1707 W CHARLESTON BLVD | ||||||||
Address2: | #160 | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891022351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026715150 | ||||||||
FaxNumber: | 7023846493 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 06/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | 12333 | NV | N |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | MD60484880 | WA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0102X | 12333 | NV | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 208600000X | 12333 | NV | N |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | BC9921380 | 01 | NV | DEA CERTIFICATE | OTHER | 12333 | 01 | NV | MEDICAL LICENSE | OTHER | CS14261 | 01 | NV | PHARMACY CERTIFICATE | OTHER |