Basic Information
| Provider Information | |||||||||
| NPI: | 1780694620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARSON MEDICAL GROUP PROFESSIONAL CORPORATION | ||||||||
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| OtherOrganizationName: | CARSON MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N. MOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897033827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758833555 | ||||||||
| FaxNumber: | 7758822382 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 MOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897033821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758835555 | ||||||||
| FaxNumber: | 7758822382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | SANDERS | ||||||||
| AuthorizedOfficialFirstName: | MARIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | QUALITY & RESOURCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7752805075 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.