Provider Demographics
NPI:1609063627
Name:RANCHO INTERNAL MEDICINE GROUP PC
Entity Type:Organization
Organization Name:RANCHO INTERNAL MEDICINE GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANIT
Authorized Official - Middle Name:
Authorized Official - Last Name:DUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-477-7044
Mailing Address - Street 1:7010 SMOKE RANCH RD
Mailing Address - Street 2:120
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-3123
Mailing Address - Country:US
Mailing Address - Phone:702-477-7044
Mailing Address - Fax:702-388-1664
Practice Address - Street 1:7010 SMOKE RANCH RD
Practice Address - Street 2:120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-3123
Practice Address - Country:US
Practice Address - Phone:702-477-7044
Practice Address - Fax:702-388-1664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV9751207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVWCHBDMedicare PIN