Healthcare Provider Details

I. General information

NPI: 1598003014
Provider Name (Legal Business Name): UNSOM MULTISPECIALTY GROUP PRACTICE SOUTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 S MARYLAND PKWY SUITE 400
LAS VEGAS NV
89109-2307
US

IV. Provider business mailing address

1701 W CHARLESTON BLVD SUITE 490
LAS VEGAS NV
89102-2325
US

V. Phone/Fax

Practice location:
  • Phone: 702-650-2500
  • Fax: 702-650-2220
Mailing address:
  • Phone: 702-671-2278
  • Fax: 702-671-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JOANNE HANSEN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 702-671-2395