MEDICARE: DIGNITY HEALTH MEDICAL GROUP NEVADA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	363L00000X	Nurse Practitioner
3	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1356850440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIGNITY HEALTH MEDICAL GROUP NEVADA LLC

Provider Business Mailing Address
First Line	:	2200 PASEO VERDE PKWY STE 260
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-2703
Country	:	US
Telephone Number	:	702-616-5786
Fax Number	:

Provider Business Practice Location Address
First Line	:	8689 W CHARLESTON BLVD STE 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5485
Country	:	US
Telephone Number	:	702-616-5801
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MELISSA WALKER
Credential	:
Telephone Number	:	702-616-5507

Provider Enumeration Date	:	09/21/2017
Last Update Date	:	09/21/2017

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