Provider Demographics
NPI:1417080839
Name:UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO
Entity Type:Organization
Organization Name:UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO
Other - Org Name:MEDSCHOOL ASSOCIATES SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-992-6888
Mailing Address - Street 1:PO BOX 29506
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89126-9506
Mailing Address - Country:US
Mailing Address - Phone:702-968-4371
Mailing Address - Fax:702-671-5170
Practice Address - Street 1:1707 W CHARLESTON BLVD
Practice Address - Street 2:110B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2351
Practice Address - Country:US
Practice Address - Phone:702-968-4363
Practice Address - Fax:702-671-0193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical CytogeneticsGroup - Multi-Specialty
No207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical GeneticsGroup - Multi-Specialty
No207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular GeneticsGroup - Multi-Specialty
No207SG0205XAllopathic & Osteopathic PhysiciansMedical GeneticsPh.D. Medical GeneticsGroup - Multi-Specialty
No207SM0001XAllopathic & Osteopathic PhysiciansMedical GeneticsMolecular Genetic PathologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500484Medicaid
NV100500484Medicaid