MEDICARE: FAMILY TREE MEDICAL CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9897	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508870445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY TREE MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 231930
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89105-1930
Country	:	US
Telephone Number	:	702-947-1000
Fax Number	:	702-947-1001

Provider Business Practice Location Address
First Line	:	3510 E TROPICANA AVE
Second Line	:	STE # K
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-7341
Country	:	US
Telephone Number	:	702-947-1000
Fax Number	:	702-947-1001

Authorized Official
Title or Position	:	OWNER
Name	:	TONY GUMINA
Credential	:	MD
Telephone Number	:	702-947-1000

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	04/30/2013

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