Provider Demographics
NPI:1750372140
Name:TAHOE FRACTURE & ORTHOPEDIC MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:TAHOE FRACTURE & ORTHOPEDIC MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-783-6190
Mailing Address - Street 1:973 MICA DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89705-7255
Mailing Address - Country:US
Mailing Address - Phone:775-783-6190
Mailing Address - Fax:775-783-6191
Practice Address - Street 1:973 MICA DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89705-7255
Practice Address - Country:US
Practice Address - Phone:775-783-6190
Practice Address - Fax:775-783-6191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363L00000X, 363A00000X, 207XS0106X, 207XS0117X, 207X00000X
NV1006213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC4631OtherBCBS
NV100506168Medicaid
CAC03071OtherRAILROAD
NVCH0545OtherRAILROAD
CAZZZ49317ZOtherMEDI-CAL
NVCC4631OtherBCBS
NV100506168Medicaid
CAZZZ49317ZOtherMEDI-CAL
CA0478150001Medicare NSC
NV0478150007Medicare NSC
NV0478150004Medicare NSC