MEDICARE: MOUNTAIN VALLEY PHYSICIAN GROUP, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	207V00000X	Obstetrics & Gynecology Physician
3	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235327909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN VALLEY PHYSICIAN GROUP, LLC

Provider Business Mailing 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

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	:	MANAGER
Name	:	MARK STODDARD
Credential	:
Telephone Number	:	775-751-7519

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	08/31/2010

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