Provider Demographics
| NPI: | 1184601239 |
|---|---|
| Name: | UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO |
| Entity type: | Organization |
| Organization Name: | UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | ELISSA |
| Authorized Official - Middle Name: | J |
| Authorized Official - Last Name: | PALMER |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 702-992-6888 |
| Mailing Address - Street 1: | PO BOX 29506 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | LAS VEGAS |
| Mailing Address - State: | NV |
| Mailing Address - Zip Code: | 89126-9506 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 702-671-2330 |
| Mailing Address - Fax: | 702-671-5170 |
| Practice Address - Street 1: | 1701 W CHARLESTON BLVD |
| Practice Address - Street 2: | #110 |
| Practice Address - City: | LAS VEGAS |
| Practice Address - State: | NV |
| Practice Address - Zip Code: | 89102-2325 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 702-671-2395 |
| Practice Address - Fax: | 702-382-5388 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2005-12-29 |
| Last Update Date: | 2015-10-14 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 208000000X, 2084N0400X, 208600000X, 261QM1300X, 291U00000X, 133NN1002X, 170300000X, 207Q00000X, 207SG0201X, 207SG0205X, 207V00000X, 207R00000X | ||
| NV | 367A00000X, 363L00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
| No | 291U00000X | Laboratories | Clinical Medical Laboratory | Group - Multi-Specialty | |
| No | 133NN1002X | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | Group - Multi-Specialty |
| No | 170300000X | Other Service Providers | Genetic Counselor, MS | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207SG0201X | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | Group - Multi-Specialty |
| No | 207SG0205X | Allopathic & Osteopathic Physicians | Medical Genetics | Ph.D. Medical Genetics | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NV | 100500484 | Medicaid | |
| NV | VWQBHV | Medicare PIN |
