Basic Information
| Provider Information | |||||||||
| NPI: | 1821121310 | ||||||||
| 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: | 890 MILL ST | ||||||||
| Address2: | 102 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753222731 | ||||||||
| FaxNumber: | 7753222790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | PALMER | ||||||||
| AuthorizedOfficialFirstName: | ELISSA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7029926888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 000640 | NV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 363L00000X | 000640 | NV | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2416097 | 05 | NV | MEDICAID | 100500484 | 05 | NV | MEDICAID |