Provider Demographics
NPI:1912148123
Name:CARSON MEDICAL GROUP
Entity Type:Organization
Organization Name:CARSON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-883-3636
Mailing Address - Street 1:1200 MOUNTAIN ST.
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703
Mailing Address - Country:US
Mailing Address - Phone:775-883-3636
Mailing Address - Fax:775-882-2382
Practice Address - Street 1:1470 MEDICAL PARKWAY
Practice Address - Street 2:STE 110
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703
Practice Address - Country:US
Practice Address - Phone:775-883-3636
Practice Address - Fax:775-882-2382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN001101207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty