Provider Demographics
NPI:1124334776
Name:TAHOE CARSON VALLEY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:TAHOE CARSON VALLEY MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:BERGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-589-8900
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:155 HWY 50
Practice Address - Street 2:
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449-9800
Practice Address - Country:US
Practice Address - Phone:775-589-8900
Practice Address - Fax:775-588-7110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV5502710001Medicare NSC