Basic Information
| Provider Information | |||||||||
| NPI: | 1992842660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF NEVADA SCHOOL OF MED MULTISPECIALTY GROUP PRACTICE NORTH | ||||||||
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| OtherOrganizationName: | RENOWN MEDICAL SCHOOL ASSOCIATES NORTH, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1155 MILL ST # MCM14 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
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| Practice Location | |||||||||
| Address1: | 745 W MOANA LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895094991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759821000 | ||||||||
| FaxNumber: | 7759828046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | BECK | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO RENOWN HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 7759826488 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 208D00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100500708 | 05 | NV | MEDICAID |