Provider Demographics
| NPI: | 1508865528 |
|---|---|
| Name: | TAHOE CARSON VALLEY MEDICAL GROUP INC |
| Entity Type: | Organization |
| Organization Name: | TAHOE CARSON VALLEY MEDICAL GROUP INC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | DAVID |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | YOUNG |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 775-589-8916 |
| Mailing Address - Street 1: | 2170 SOUTH AVE |
| Mailing Address - Street 2: | |
| Mailing Address - City: | SOUTH LAKE TAHOE |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 96150-7026 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 530-543-5659 |
| Mailing Address - Fax: | 530-541-8723 |
| Practice Address - Street 1: | 2170 SOUTH AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | SOUTH LAKE TAHOE |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 96150 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 530-541-3420 |
| Practice Address - Fax: | 530-541-8723 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2005-07-20 |
| Last Update Date: | 2023-06-12 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CA | USA293250 | Other | BLUE SHIELD OF CA |
| CA | XGG007610 | Medicaid | |
| CA | ZZZ14014Z | Other | BLUE SHIELD OF CA |
| CA | GR0055022 | Medicaid | |
| CA | GR0055023 | Medicaid | |
| CA | USA293170 | Other | BLUE SHIELD OF CA |
| CA | USA292950 | Other | BLUE SHIELD OF CA |
| CA | USA292960 | Other | BLUE SHIELD OF CA |
| CA | USA292970 | Other | BLUE SHIELD OF CA |
| CA | ZZZ61294Z | Other | BLUE SHIELD OF CA |
| NV | 100506149 | Medicaid | |
| CA | GR0055020 | Medicaid | |
| CA | ZZZ54133Z | Other | BLUE SHIELD OF CA |
| CA | XGG007612 | Medicaid | |
| CA | ZZZ65882Z | Other | BLUE SHIELD OF CA |
| CA | 100506911 | Medicaid | |
| CA | GR0055021 | Medicaid | |
| CA | XGG007611 | Medicaid | |
| CA | ZZZ61294Z | Other | BLUE SHIELD OF CA |
| CA | GR0055020 | Medicaid |
