MEDICARE: JACK ANSTANDIG MD PROFESSIONAL CORPORATION

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	174400000X	Specialist	13232	NV

General Provider Information

NPI Number	:	1992038152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACK ANSTANDIG MD PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	8475 S EASTERN AVE
Second Line	:	SUITE 202
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-2862
Country	:	US
Telephone Number	:	866-972-5182
Fax Number	:	866-972-5183

Provider Business Practice Location Address
First Line	:	8475 S EASTERN AVE
Second Line	:	SUITE 202
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-2862
Country	:	US
Telephone Number	:	866-972-5182
Fax Number	:	866-972-5183

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JACK ANSTANDIG
Credential	:	M.D.
Telephone Number	:	866-972-5182

Provider Enumeration Date	:	09/04/2009
Last Update Date	:	09/04/2009

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