Provider Demographics
NPI:1508811084
Name:PROVIDER NETWORK, INC
Entity Type:Organization
Organization Name:PROVIDER NETWORK, INC
Other - Org Name:FERNLEY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:T
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-982-6488
Mailing Address - Street 1:1155 MILL ST # M14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:1343 NEWLANDS DR W
Practice Address - Street 2:
Practice Address - City:FERNLEY
Practice Address - State:NV
Practice Address - Zip Code:89408-8926
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-6504
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOMETOWN HEALTH MANAGEMENT COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCG0436OtherRR MEDICARE PTAN
NVV30340Medicare PIN