Provider Demographics
NPI:1750556940
Name:GREAT WEST MEDICAL ASSOCIATES CARROL LLP
Entity type:Organization
Organization Name:GREAT WEST MEDICAL ASSOCIATES CARROL LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-220-9865
Mailing Address - Street 1:PO BOX 34795
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-4795
Mailing Address - Country:US
Mailing Address - Phone:702-220-9865
Mailing Address - Fax:702-251-8196
Practice Address - Street 1:3150 N TENAYA WAY
Practice Address - Street 2:SUITE 525
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0443
Practice Address - Country:US
Practice Address - Phone:702-220-9865
Practice Address - Fax:702-251-8196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1750556940Medicaid
NV1750556940Medicaid