MEDICARE: PORTNEY MEDICAL GROUP LTD

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	207R00000X	Internal Medicine Physician	9534	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	:	1962604884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTNEY MEDICAL GROUP LTD

Provider Business Mailing Address
First Line	:	810 S DURANGO DR
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-2423
Country	:	US
Telephone Number	:	702-240-0874
Fax Number	:	702-240-3627

Provider Business Practice Location Address
First Line	:	9417 QUEEN CHARLOTTE DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-8707
Country	:	US
Telephone Number	:	702-240-0874
Fax Number	:	702-240-3627

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. ALEXANDER LEON PORTNEY
Credential	:	MD
Telephone Number	:	702-240-0874

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	12/03/2010

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