=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912175886
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC JUSTIN REAM MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2008
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 N TENAYA WAY
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-0436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-915-3600
-----------------------------------------------------
Fax | 972-915-3636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9229 LBJ FWY STE 250
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75243-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-346-0747
-----------------------------------------------------
Fax | 972-739-2638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 13237
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207PE0004X
-----------------------------------------------------
Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 13237
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------