Provider Demographics
NPI:1366681538
Name:MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:JAYSON
Authorized Official - Last Name:PUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-638-7705
Mailing Address - Street 1:9315 W SUNSET RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5011
Mailing Address - Country:US
Mailing Address - Phone:702-638-7705
Mailing Address - Fax:702-638-7706
Practice Address - Street 1:9315 W SUNSET RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5011
Practice Address - Country:US
Practice Address - Phone:702-638-7705
Practice Address - Fax:702-638-7706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12103207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
207RG0600XOtherTAXONOMY
NV100511248Medicaid
NV1215009782OtherNPI