Provider Demographics
NPI:1962604884
Name:PORTNEY MEDICAL GROUP LTD
Entity type:Organization
Organization Name:PORTNEY MEDICAL GROUP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:PORTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-240-0874
Mailing Address - Street 1:810 S DURANGO DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-2423
Mailing Address - Country:US
Mailing Address - Phone:702-240-0874
Mailing Address - Fax:702-240-3627
Practice Address - Street 1:9417 QUEEN CHARLOTTE DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-8707
Practice Address - Country:US
Practice Address - Phone:702-240-0874
Practice Address - Fax:702-240-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9534207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506921Medicaid
NV100506921Medicaid