Provider Demographics
NPI:1376891572
Name:NORTHERN NEVADA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:NORTHERN NEVADA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-768-3300
Mailing Address - Street 1:367 S GULPH RD
Mailing Address - Street 2:C/O REIMBURSEMENT
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:610-382-4351
Mailing Address - Fax:775-356-5590
Practice Address - Street 1:2385 E PRATER WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-9629
Practice Address - Country:US
Practice Address - Phone:775-356-4888
Practice Address - Fax:775-356-4890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies