Provider Demographics
NPI:1730280330
Name:SHADOW MOUNTAIN SURGERY CENTER
Entity Type:Organization
Organization Name:SHADOW MOUNTAIN SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:I
Authorized Official - Last Name:MALITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-421-2020
Mailing Address - Street 1:7135 W SAHARA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-2828
Mailing Address - Country:US
Mailing Address - Phone:812-421-2020
Mailing Address - Fax:812-422-1189
Practice Address - Street 1:7135 W SAHARA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2828
Practice Address - Country:US
Practice Address - Phone:812-421-2020
Practice Address - Fax:812-422-1189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2000044-426261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV34468Medicare ID - Type Unspecified