Provider Demographics
NPI:1588698765
Name:PRIMARY SPECIALTIES MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:PRIMARY SPECIALTIES MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:NATHANIAL
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:702-434-0059
Mailing Address - Street 1:3365 E FLAMINGO RD
Mailing Address - Street 2:#4
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7440
Mailing Address - Country:US
Mailing Address - Phone:702-434-0059
Mailing Address - Fax:702-436-0060
Practice Address - Street 1:3365 E FLAMINGO RD
Practice Address - Street 2:#4
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7440
Practice Address - Country:US
Practice Address - Phone:702-434-0059
Practice Address - Fax:702-436-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100226Medicare ID - Type UnspecifiedNORIDIAN