MEDICARE: PAHRUMP GASTROENTEROLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	NV20111561669	NV

General Provider Information

NPI Number	:	1164705547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAHRUMP GASTROENTEROLOGY LLC

Provider Business Mailing Address
First Line	:	2136 E DESERT INN RD
Second Line	:	STE A
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-3247
Country	:	US
Telephone Number	:	702-734-0505
Fax Number	:	702-734-3912

Provider Business Practice Location Address
First Line	:	360 S LOLA LN
Second Line	:
City	:	PAHRUMP
State	:	NV
Zip	:	89048-0884
Country	:	US
Telephone Number	:	775-751-7580
Fax Number	:	775-751-7820

Authorized Official
Title or Position	:	OWNER
Name	:	DR. OSAMA OMAR HAIKAL
Credential	:	M.D.
Telephone Number	:	702-734-0505

Provider Enumeration Date	:	09/22/2011
Last Update Date	:	09/22/2011

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