Provider Demographics
NPI:1649923400
Name:INTEGRATED MULTI SPECIALTY MEDICAL GROUP
Entity type:Organization
Organization Name:INTEGRATED MULTI SPECIALTY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-569-7244
Mailing Address - Street 1:801 S RANCHO DR STE A2
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3870
Mailing Address - Country:US
Mailing Address - Phone:702-483-3630
Mailing Address - Fax:
Practice Address - Street 1:1440 E NEVADA HIGHWAY 372 STE 3
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-2184
Practice Address - Country:US
Practice Address - Phone:702-483-3630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty