Provider Demographics
NPI:1013316165
Name:UNIVERSITY OF NEVADA SCHOOL OF MEDICINE MULTI-SPEC GRP PRACT SO
Entity Type:Organization
Organization Name:UNIVERSITY OF NEVADA SCHOOL OF MEDICINE MULTI-SPEC GRP PRACT SO
Other - Org Name:MEDSCHOOL ASSOCIATES SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-671-2395
Mailing Address - Street 1:1701 W CHARLESTON BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2325
Mailing Address - Country:US
Mailing Address - Phone:702-671-2211
Mailing Address - Fax:702-380-2913
Practice Address - Street 1:2231 W CHARLESTON BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2254
Practice Address - Country:US
Practice Address - Phone:702-676-3650
Practice Address - Fax:702-676-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500484Medicaid
NVVWQBHVMedicare UPIN