Provider Demographics
NPI:1447576111
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:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZAMBONI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-671-2278
Mailing Address - Street 1:1707 W CHARLESTON BLVD
Mailing Address - Street 2:200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2351
Mailing Address - Country:US
Mailing Address - Phone:702-671-6475
Mailing Address - Fax:702-671-5090
Practice Address - Street 1:1707 W CHARLESTON BLVD
Practice Address - Street 2:200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2351
Practice Address - Country:US
Practice Address - Phone:702-671-6475
Practice Address - Fax:702-671-5090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV91262084A0401X, 2084P0800X
NVPY03202084A0401X, 2084P0800X
NV77332084A0401X, 2084P0800X
NV76112084P0800X, 2084P0804X
NV121602084P0800X, 2084P0802X
NVPY3202084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500484 GROUPMedicaid
NVVWQBHVMedicare PIN