Healthcare Provider Details

I. General information

NPI: 1477686004
Provider Name (Legal Business Name): UNIVERSITY OF NV SCHOOL OF MEDICINE MULTI SPECIALTY GROUP PRACTICE SO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 E TWAIN AVE
LAS VEGAS NV
89169-4905
US

IV. Provider business mailing address

PO BOX 29506
LAS VEGAS NV
89126-9506
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-2200
  • Fax: 702-671-2233
Mailing address:
  • Phone: 702-696-8437
  • Fax: 702-671-5170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State

VIII. Authorized Official

Name: ELISSA J. PALMER
Title or Position: PRESIDENT
Credential: MD
Phone: 702-992-6888