Healthcare Provider Details

I. General information

NPI: 1417080839
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: 03/14/2007
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W CHARLESTON BLVD 110B
LAS VEGAS NV
89102-2351
US

IV. Provider business mailing address

PO BOX 29506
LAS VEGAS NV
89126-9506
US

V. Phone/Fax

Practice location:
  • Phone: 702-968-4363
  • Fax: 702-671-0193
Mailing address:
  • Phone: 702-968-4371
  • Fax: 702-671-5170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207SG0205X
TaxonomyPh.D. Medical Genetics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207SM0001X
TaxonomyMolecular Genetic Pathology (Medical Genetics) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License Number
License Number State

VIII. Authorized Official

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