Healthcare Provider Details

I. General information

NPI: 1184601239
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: 12/29/2005
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W CHARLESTON BLVD #110
LAS VEGAS NV
89102-2325
US

IV. Provider business mailing address

PO BOX 29506
LAS VEGAS NV
89126-9506
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-2395
  • Fax: 702-382-5388
Mailing address:
  • Phone: 702-671-2330
  • Fax: 702-671-5170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code207SG0205X
TaxonomyPh.D. Medical Genetics Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateNV
# 13
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNV
# 14
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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